Loading...
HomeMy WebLinkAbout0101 WINDSHORE DRIVE - Health 101 WINDSHORE DRIVE, HYANNIS A= 271 139 r I No. , C© Y Fee J / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ✓ Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01ppItration for M.5pogo.Y *pmem Cong;truction VCrmtt Application for a Permit to Construct( )Repair( )Upgrade(�,J'Abandon( ) ❑Complete System KIndividual Components Location Address or Lot No.O�l /JC/ ��u Owner's Name,Address and Tel.No. Assessor's Ma /Parcel G ,Assess &-r-if p � � I Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures , Design Flow -�3o gallons per day. Calculated daily flow 73 �cl gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank i--->cr s`i L672 eta- !j. Type of S.A.S. r �— Description of Soil, 4\.Xe S Fd o Nature of Repairs or Alterations(Answer when applicable) kJ u D U T 1 L`C"'CV0 1 5. Sc 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 E ironmental Code and not to place the system in operation until a Certifi- cate of Compliance has bee f e. th. Signed Date Application Approved by Date F—I,�F' � Application Disapproved for the following reasons Permit No. 7P� 9(5 Date Issued / 1 1 f yd No. Fee THE COMMONWEALTH OF MASSACHUSETTS, Entered in computer: Yes PUBLIC'HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZippYication for'�Digpooal *p5tem Construction Permit y Application for a Permit to Construct( ).Repair( )Upgrade( )Abandon( ) ❑Complete System KIndividual Components Location Address or Lot No.7VI "" >. Owner's Name,Addres and Tel.No. Y�� S _1:, Assessor's Map/Parcel a� � ' 3 Installe Ve, C.-dqd T�h Ng,� ovIs aa s((� t Designer's Name,Address and Tel.No. l�It1 l 1, 6Ty Type of Building: 2 Dwelling No.of Bedrooms J Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures �j Design Flow �'3o gallons per day. Calculated daily flow ° gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank �S I �� "V Type of S.A.S. `� Description of Soil 5 i Na 3vlrt'CJ�f R pairs sr Iterations(Answer I hen applicable e. tt_Tl 11 ( CJ� O K I �L� Date last inspected: *�•� Agreement: The undersigned agrees to ensrure the construction and maintenance of the afore described on-site sewage disposal system; in accordance with the provisions of Title 5 of the Vvironmental Code and not to place the system in operation until a Certifi- cate of Compliance has be ue\dby this /�� Signed 1 Date t Application Approved by Date _ l� Application Disapproved for the following reasons Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance Y THIS IS TO CERTIFY,yak rho,On�site�S��p ag�Di„sp � stem Constructed( )Repaired( )Upgraded( ) Abandoned( )by 4/ C_at ri-Y 4t i` t ' �een constructed i accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. . datedg���� � Installer Designer The issuance of s pe t@slial o t construed as a guarantee that the-systemi.l function a esigned. Date � a �`- Inspector � ��,11 No. --------------------------Fee -Z 1 l— r 37 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE. MASSACHUSETTS 10igo0ai *pztem Construction permit Permission is hereby granted to Construct( )Repair( )Upgrade Abandon( ) System located at /A c KIv y/CA r2 rn r' 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. Provided:Co /�rn t b completed within three years of the date of i�rmit. Date: r Approved by'�� lf—� 1/6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. 4 � CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) hereby certify that the applicatio n for disposal works construction permit signed by me dated �f`��'� , concerning the property located at l U jA meets all of the following criteria: t- This failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. <s,There are no wetlands within 100 feet of the proposed septic system 0- "There are no private wells within 150 feet of the proposed septic system ere is no increase in flow and/or change in use proposed There are no variances requested or needed. bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] e✓ff the S.A.S.will be located with 250 feet of any vegetated wetlands,the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted ,groundwater table elevation, Please complete the following: l� A) Top of Ground Surface levation(using GIS information) �V r B) G.W.Elevation +the MAX.High G.W.Adjustment. _ d DIFFERENCE BETWEEN A and B 2� , SIGNED : DATE: [Please Sketch proposed plan of system on back]. NOTICE , Based upon the above information,a repair permit will be issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans. q:health folder:cert �� U� �� d�C � � � � � P a �� s, � -� �;� ,� ^, �� � � � �• 0 r -� yZ°��1 .. o TOWN yO�F�BARNSTt-BLE LOCATION OCR 91 SEWAGE # VELLAGE u ASSESSOR'S MAP & LOT -61V—C�l INSTALLER'S NAME&PHONE NO. M l� SEPTIC TANK CAPACITY X I LEACHING FACR rT-Y: ( :pe) NO. OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted.Ground water Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by C- ' 00 / it ire^ ASP-H --�(2 Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection William F.WeldGovemor Tnrdy Coxe Atgeo Paul Cellucal seffet ry is ooweta DWW B.Slruhs Q SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM I PART A _ �C���j�, I I CERTIFICATION �fr;(J,q y 4rhp Property Address: 101 W1,vostt#k U `DA_ 4fA-A/,l/1S Address of Owner. f� r+ 4r ,9 1 Of�P� 4ll7lq(, of different) ,I'9 6 Name of Inspector. A-A/o Qli Uj P*A Z-Aj 1>A/.T Company Name,Address and Telephone Number. 116.0- a^ at� C6 VrseViwvJ1A,4 0;.(13 g CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,aoaaste and complete as of the time of inspection. The inspection was performed based on my training and ezperience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: )J, �L Data 4l(`1l L(Y The System Inspector shall submit a copy of thisinspection report to the Approving Authority within thirty(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: Check A,B, C,or D: A] SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CM$ 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection- Indicate yes,no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined The septic tank is metal, cracked,structuraII Plain illy re i y unsound,shows substantial infiltration or esfiltration,.or teak failure is +*�*r++r+�nt. The system will pass inspection if the musting septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 11/03/95) 1 One Wlnter Street • Boston,Massachusetts 02108 a FAX(611)556-1049 • Telephone(611)292-WW 40 Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner. Date of Inspection: III SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution boat is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution boat. The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced _ 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 Cl FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The 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 hee from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. 3) OTHER (revised 11/03/95) 2 l I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A • CERTIFICATION(continued) Property Address: 101 MA/0S(.4-0 ktr DPI, AA- Owner. AAAPv- D Date of Inspection: 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. _ Backupof se into facility or wage ' ty system component due to an overloaded or clogged 3A3 or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS,or cesspool. Static liquid level in the distribution bog above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. _ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.. (revised 11/03/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner. Date of Inspection: s Check if the following have been done: Pumping information was requested of the owner,occupant,and Board of Health. //None of the system components have been pumped for at least 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. AAs built plans have been obtained and examined. Note if they are not available with N/A. V'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. AAll system components,excluding the Soil Absorption System,have been located on the site. ZThe septic tank manholes were uncovered, opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum. il/The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. ZThe facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11/03/95) 4 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 101 LAAA/Os K-dftq- Owner. AtA-P V- Date of Inspection: �l�71gl� • SEPTIC TANX-_Z (locate on site plan) �Depth below grade:2 � _ Material of construction:Vconcrete_metal_FU_other(explain) Dimensions X Sludge depth �,z Distance from top of sludge to bottom of outlet tee or bate: Scum thickness: U 2 p Distance from top of scum to top of outlet tee or baffle:G.p Distance from bottom of scum to bottom 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.) CYC:dMM 6-uO T>L,' f P 0-16L L�V Ls Y .(i�S<i 7 PUCT U f2 L' G� _a A sO r_i4 l M A/gY A-'T Qu'T L(T'T' /n i_4/i_i T A-LP_e, O tf J t M.A/M7_& 1j GREASE TRAP: _.. (locate on site plan Depth below grade: Material of construction:_concrete_metal_FRP_other(e:plain) Dimensions: Scum thiclmess: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (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. (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner. Date of Inspection: FLOW CONDITIONS RESIDENTIAL:- Design flow:330 —gallons Number of bedrooms:, Number of current residents:3 Garbage grinder(yes or no)-AL Laundry connected to syste (yes or no): Seasonal use(yes or no):IV Water meter readings,if available: 33.dGU GU ET, .-ylA,A'P" Last date of occupancy:LumovT COMMERCIALANDUSTRIAL: Type of establishment: Design flow:_gallons/day 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: Lest date of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION ` PUMPING RECORDS and source of information: 9' . `PP—L-V(U S PL'"IE C/Gv�ll System pumped as part of inspection: (yes or no) If yes,volume pumped: gallons Reason for pumping: TYPE F SYSTEM Septic tanWilistribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records, if any) Other(explain) APP TE AGE of all components, date installed(if known)and source of information: Sewage odors detected when arriving at the site: (yes or no),,_ (revised 11/03/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: h ( U/t vOS 90&e Dry Owner. /lithe DV 6VAy Date of Inspection: TIGHT OR HOLDING TANK:- (locate on site plan) Depth below grade: Material of construction:_concrete_metal_FRP_other(ezplain) _ Dimensions: Capacity: ¢allons Design flow: pllons/day Alarm level: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BO • �� 17 (locate on site plan) Depth of liquid level above outlet inert:- OA/. us' ) Comments: (note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box,etc.)L6-7(l&-L; d/d Slo,//S , c::' Le,y( ej-r'&' dR �aLraS T(�v� r�✓�ss�-h 3 Y Dcf c�/ �P[ ti' rl cJf;s= �� Iaii�J LA-t)A/eRy 1 PUMP CHAMBER- (locate on Bite plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber,condition of pumps and appurtenances, etc.) (revised 11/03/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner. Date of Inspeotion: SOIL ABSORPTION _ SYSTEM (SAS): (locate on site plan,if possible;excavation not required,but may be approximated by non-intmisive methods) If not determined to be present,explain: Type: leaching pits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields, number,dimensions: overflow cesspool, number: Comments: (note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,etc.) ` �={�. /l.¢1P S p 444 Da J/42 AlAlQrnlP,. OJQ 1 jec14 &40 W-r/W CESSPOOLS: - (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer. Depth of scum layer- Dimensions of cesspool: Materials of constriction: Indication of groundwater: inflow(cesspool must be pumped as part of inspection) Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) i PRIVY: (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.) (revised 11/03/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: r®( cA1 u/O s%fG e C D p„ 9Y c-s , Owner. MA RV- D v C-v.4,t Date of Inspection: �f17lq 6 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' 1A) t 1 � ( t 3ti ' � 3 DEPTH TO GROUNDWATER Depth to groundwater.�_feet p method of determination or approximation: � �(��( 'OU S L&6- OA/ PP, I-OT �'&AAJ (revisea 11103195) 9 LOCATION SEWA E PERMIT NO. VI'�LItGE INSTALLER'S N4ME & ADDRESS o B U I'L D E R OR OWNER C,4 e_ w l o DATE PERMIT ISSUED �� dam _ 77 ; DATE COMPLIANCE ISSUED da 'E oil 'A 4. L0�`C' Av'y0N ISE SEWA E PERMIT NO. ZA) lNP 57 Nor,e- b VV LAG E INSTALLER'S NAME & ADDRESS bi l r,I,) BUILDER OR OWNER ' DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED j. F � I'/ 70 -ell No..-------�--•.. ... THE COMMONWEALTH OF MASSACH'USETTS BOAR® OF HEALTH w..oU.. ......oF.-------70 ......../A.­04 W. 5.......................................... Applira tiun for Diupus al Works Tonstrnrtiun Primit Application is hereby made for a Permit to Construct (k-�'Or Repair ( ) an Individual Sewage Disposal System at ...............vZ � .............. X.......................................... cation-A Tess or t No. ..-� :� . .....!..... . .............................. �1 ��a' _ _ .....------ ........---- Owner Address W Installer Address Q Type of Building Size Lot./,-;I ....Sq. feet U Dwelling—No. of Bedrooms........... ................ .Expansion Attic ( ) Garbage Grinder aOther—Type of Building ........................... No. of persons............................ Showers ( ) Cafeteria ( ) Other fixtures .-.-.. ?_ ...................... -•------------•-••-------------•-----•----•-------•-•-------------•--•---------....------•-•-•-•-- -- . DesignFlow..................... .... ..... -a Ions per person per day. Total daily flow.............w , P P P Y Y � gallons. WSeptic Tank/Liquid capacity./.--__- allons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width..... .._._......... Total Length.................... Total leaching area___.._ .r_.........sq. ft. Seepage Pit No14Q.V0.L . Diametepth below inlet.................... Total leaching area_.. .sq. ft. Z Other Distribution box ( ) Dosing tank ) o�. /0 -- 7- 77 ' Percolation Test Results Performed by...... ....... Date.....f k-2:.Z7............. Test Pit No. 1................minutes per inch Depth of Test it.......... Depth to ground water........................ fs, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Description of Soil..................40---` 2.... c, -.. 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 TITI.B 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health Sig ,� t � . / Date Application Approved BY.........- - - -- i r Date 27 ... lf�111---/ 2 Application Disapproved for the following reasons-------------•-------------------------------------------------•------------------.............................. ---•----•--•------------------•--••-•-----•-------....----------...........------------•--•-•--•----••....---•-•--•-•-----•-•---•---•-------•------------•-•---•-----------------------------------...... Date PermitNo......................................................... Issued-- =C 2 ..- -----------=-------- Date g7 � THE COMMONWEALTH OF MASSACHUSETTS BOARD ®F HEALTH ...........OF....... Allp iratiou for Uwvoio a11 ork,i Tons,trnrtinn ramit Application is hereby made for a Permit to Construct ( or. Repair'( ) an Individual Sewage Disposal System at "��_ z ....._ r. , ' : •� ------------------------------------------ ..� ------------- ---•• _... cation- ess or t No. * »/..... r ... ......_..^ .. .................. - -------------- -......... -- .......• ..... Y Owner Address Installer Address U Type,of°Building Size LoUVA42 ....Sq. feet Dwg 4 ellin =No. of Bedrooms.............................................Expansion Attic ( ) Garbage Grinder pa, Other—Type of.-Building ............... ___________ No. of persons.........__... Showers ( ) — Cafeteria ( ) Q' Other fixtures ---- .___ ��.....................................................................--•----•-••--- W Design Flow . .._.__ gallons per person per day. Total daily flow...... .................gallons. WSeptic Tank—Liquid capacity/..-.-__. allons Length................ Width................ Diameter._--:.......... Depth................ x Disposal Trench No. .............. W.i�th... �.__._. . Total Length.................... Total leaching area...._]j� _ sq. ft. Seepage Pit NA 0 Diamete�f� A epth below inlet..............•..... Total leaching area.'...9,;1..sq. ft. z Other Distribution box ( -.)' Dosin t nk ) oh- IV 7- 97 Percolation Test Results Performed b .`......_....._ K eols. .!........ Date:.. ✓A.":-7'-�7_____________. Y aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes er inch ,De th of Test Pit_._____....._._.._.. De th to g round water.___._.............._... P P P S -------- ----•--.-----_ . Description of Soil « ._... .�_-- '� "�-` ---- ---•-----------•-------�-+"' --------- ---------------•-deep -- '---•------- -�----------------•-------------------- V x3 k +DetiCt'.-...... UNature 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'I'IE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been u y the board of heF It . ,. Sig ate ••------ �p D Application Approved By. .._. 1 •_._.. -- ---- r? ` .Y-27----- .� Date Application Disapproved for the following reasons:................_•....................................7----------.-------------------------------------------- 7------------------------------- ......... = ---------------•- -- ---- ............................................... • :.'t ` ?�Permit No......----•----••• -------- ------------------------- Issued ......-------- -_._.. ......_...... n Date THE COMMONWEALTH_ OF MASSACHUSETTS BOARD QF HEALTH ..................... .OF....... ................................... q, Tntifiratr bf Tompfianrr THIS IS TO E TIF t S-the Individual Sewage Disposal stem constructed fr Repaired l g P �' o P ( ) by `'`5.. ....................................................•----------------------------------•-------------•-----•--------------- Installer atew ..... ............. ,a". © - r"-! ---------• �- ,°% ................................................ been installed in accordance with the provisions of,T IZ 5 of 1'he State Sanitary Code as described in the application for Disposal Works Construction Permit No... . ....a..�"........................ dated._../_�" .y`_�7._..._._.._..... THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS UARANTEE THAT THE SYSTE4 W11.L F NCTION SATISFACTORY. - 1 , DATE.... d ? ---•-----. ___----f...... ........�-----...----------- Ins tor....---- ------•-------•------...-•---.......----- THE COMMONWEALTH OF MASSACHUSETTS �{ BOARD F HEALTH ✓4.:;'1 e�...........OF. ...... � 'L�l'.R ............................................. No.......................... FEE...j'��............... %p orsa1 Works Tnntrnrtion amit Permission is hereby granted = - ...................................................................Cons rustgr-R�ir ( a s'ndividual Sewage Disposal tem atNo. ------. a ............ ... street/ as shown on the application for Disposal Works Construction P it o �, _..._.._._ Dated..../. _ _ ..... 7 ......; s. ...................... Board of ealth DATE................... FORM 1255 HOBBS & WARREN, INC., PUBLISHERS b+dt��! FL.r�w I tp ,c 3 • '�3o G.pt7:� / -. . .. _ _ SEFsT'IG T�itC _ -S&ov ISO % • 4q5 o0o CAL-. OC DISPOSAL• PIT - USE l0no GAt .', --WGWALL AtzEA = 15o S 1=. PST ` 1 8�I-1vJNI ,dIZEA= G� 51=. I i M," v t So s>=. YE ► .o - = 50 c-,.PD. ` E 0 ' ' T��nc PROP o TOTAL 'DES,16W c 4SS G.RD. r ! N D.[;vz=- �o. NS@• . TbTo L;-t>A-1 LNf 1=L.ow PlwcDL.ATlotJ 1zl�TE al►.t � 2.�rtl►.I�0t2 ... I .wa �• I I 1 �O 1 �. RI CHARD �i+ AA. l f m\ + I r f {� 1310 AX7ER E � P#io.�^•1Y>8 �U � ,:.1iu� ` N 1 ! f'�`4 f � i..E I I 1 1 _ .. � �, I ' I ..i_.... ,�,' r lik �� '" . . .. � � 3 ' ` � f i iM1i • `.I � �� qy.a . 'roP F•wo s�oo.o•1 j' I 98 8 ��. 9 3 Trz�i' ¢'PPS vlsr. Iw• 6AL. , SuBSOOL : -BoX `IG.4 SEvnc V. ip 4 Iuv T'.n N K LAYF-R8 : loop 96.1 INV. 11N •.� Div -GAL . qG.o 9t..Z 1-EAc o 'A 5.NNDY T PIT i GRAVCL6. WtTt1 �' a '� Z 5To►Jt� 69. MEDIUM D uM i CEtZT11=11tlD PLC> .4, 5A y D PIzO�=-1 L 1`bCA T l O tJ HYAN N\S = 40' b A`r C- 10 1-7 GGtZTt1=-f lrJ.(A-(' T14G TWWl LI13 'SuavtJ 1ZL-r"�IZ�uCt= tv-lV2, Mm►a oCoM%PLVlo- W(Tt4 TPC:. Lo -r S . A► t> SCTt3-Ac.4 vr--QujQGm& •lTc, OPTHE . 1.• G. 3 -7 G G 6,A -Toww cl� a►Z? �' T APp�-� n (� W EST \N ooa,. RCGtSrGtZi=tom 1-ti�IG ,UeV`Yor`S ' T141'S M-AW (-.*. d-JOT U-1 A:,r--V Ut--1 A&A 05TEV-V1l_LG A��ht_1 <_A.ti.1T 1'•!if (;:t: Ul,>CD '1"0 1>r1'ct",MI�Jt� 1.C��!' t_11.tc_:�:, - ., Cr�iFE W1 rJE ��vEt_. Co. TOWN yyO��FBARNSTMLE LOCATION 4C SEWAGE # VILLAGE- � ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. i c � SEPTIC TANK CAPACITY:'^� J�S LEACHING FACILITY: ( pe) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: LIZ WO-0— COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility, Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 5 � L. ,L C O p _ 1 -Ti✓Fo 7/',4tor 'f