HomeMy WebLinkAbout0107 ANCHOR LANE - Health 107 ANCHOR LANE;COTUIT
A=024-134
OMEN
TKO WN OF BARNSTABLE
LOCATION I fJ A-�f't/e SEWAGE #
VILLAGE (zr a ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. S - -7
SEPTIC TANK CAPACITY �y-b
LEACHING FACILITY: (type) /kd _(size)
NO. OF BEDROOMS
BUILDER OR OWNER
PERMIT DATE: s3 /" COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom6f ' aching Facility Feet
Private Water Supply Well and Leaching Facility y wells exist
on site or within 200 feet of leaching facility) Feet
'Edge of Wetland and Leaching Facility(If any [lands exist
within 300 feet of leaching facility) Feet
Furnished by
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L" 0 SAT ��7. 127
ION SEWAGE PERMIT N0.
4AIC111Cl/Z 114m&- 79- afro
VILLAGE Cc,,? 17.41?ly l?
INSTA LLER'S NAME & ADDRESS
Y)oe?G
B U I L D E R OR OWNER
DATE PERMIT ISSUED �/!1 �y /97i
DATE COMPLIANCE ISSUED _ ��`- 7q ,
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No. — G y Fee$5 0.00 /
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
0(pp ratton for Mi$po!6a1 *potent Cott.5truction Vertu
Application for a Permit to Construct( )Repair(x )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 1 0 7 Anchor Lane Owner's Name,Address and Tel.No. 61 7—5 2 7—8 9 4 6
Assessor'sMap/Parcel Cotuit, MA Koby Rotstein 45 Fenwick Rd
Newton, MA 02468
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 Service
PO Box 1089, Centerville, MA 0263
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq. ft. 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
Size of Septic Tank Type of S.A.S.
Description of Soil sand
Nature of Repairs or Alterations(Answer when applicable) Install T5 Leaching system consisting
of D-Box and Three maximizers (stonepacked) , connecting to existing
septic tank.
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by th' �pdofi
Health.
Signed Gt> Date
Application Approved by Date
Application Disapproved for theYollow4 reasons
Permit No. Date Issued
No.
Fee50.00
s
THE COMMONWEALTH OF MASSACHUSETTS
Entered in computer: V'✓
Yes
PUBLIC HEALTH DIVISION'- TOWN OF BARNSTABLE, MASSACHUSETTS
Application for nizpoml *pztem Construction Permit
' Application for a Permit to Construct( )Repair(x )Upgrade( )Abandon( ) El Complete System ❑Individual Components
Location Address or Lot No. 107 Anchor Lane Owner's Name,Address and Tel.No. 61 7—5 27-8 9 4 6
Assessor'sMapTarcel Cotuit, MA Koby Rotstein 45 Fenwick Rd
Newton, MA 02468
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 Service
PO Box 1089, Centerville, MA 0263
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder(ng
Other Type of Building o5, � Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
IN Size of Septic Tank Type of S.A.S.
Description of Soilk Sand
Nature_ of•R-epairs or Alterations(Answer when applicable) Install T5 Leaching system consisting
of D-Box and Three maximizers (stonepacked) , connecting to existing
septic tank.
Date last inspected:
Agreement: try t� ti.
The undersigned agrees to ensure the construction and maintenance'of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and n4l,to place the system in operation until a Certifi-
cate of Compliance has been issued by th� oajodof Health.
Signed Date �� 0
Application Approved by +' Date ")
Application Disapproved for&Wllow4 reasons
a
i
Permit No. 9S_� q Date Issued
————————
f! TI E CA• W�EAL�H, MASSACHUSETTS ,_ ;
Rotstein
BARNSTABLE, MASSACHUSETTS '� L
Certificate of Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( ) Repaired(xx)Upgraded( )
Abandoned( )by
at 107Anchor LaKe Cotuit has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. - Clc/ dated
Installer W E Robinson Septic Service Designer
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
Date Inspector
r
No. - Fee $5 0.0 0
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Rotstein 'Wiooar 6p5tem Construction Vormit
Permission is hereby granted to Construct( )Repair( x)Upgrade( )Abandon( )
System located at 107 Anchor Lane
Cotuit, MA
Installer: W E Robinson Sefltic Sery ce
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:Construction must be completed within three years of the date of this permit.
Date:-- -�-�' _ Approved by ,�"'>
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Al.
NOTICE: This Form Is To Be Used For the Repair Of Failed
-Septic-System-s-Only.
k
CERTIFICATION OF SKETCH AND APPLICATION FOR A
DISPOSAL WORKS CONSTRUCTION.,PERMIT (WITHOUT
ENGINEERED PLANS)
I, William E. Robinson, Sr. ,hereby certify that the application for disposal works
construction permit signed by me dated ` 3/— concerning the
property located at 107 Anchor Lane, otuit, meets all of the
following criteria:
* There are no wetlands within 100 feet of the proposed leaching facility.
* There are no private wells within 150 feet of the proposed septic system.
* There is no increase in flow and/or change in use proposed.
* There are no variances requested or needed.
* If the proposed leaching facility will be located with 250 feet of any 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:
A)Top of Ground Elevation(according to the Engineering Division G.I.S. map) �4 0
B)Observed Groundwater Table Evaluation(according to Health Division well map)
SIGNED DATE
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER 20-1998
(Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan,
this plan should be submitted).
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COMMONWEALTH OF MASSACHUSETTS
f EXECUTIVE OFFICE OF ENVIRONMENTAL .'HIRS p0
DEPARTMENT OF ENVIRONMENTAL P �hE�jc ,i0
A 4z",-
ONE WINTER STREET. BOSTON. MA 02108 617-292-- 0 T
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8
5�•� 1998
WILLIAM F.WELD Y COXE
Governor Secretary
ARGEO PAUL CELLUCC] " {j `VID B.STRUHS
Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner
PART A
107 Anchor Lane CERTIFICATION
Kobyy Rotstein
Property Address: Cotuit, MA' Address of Owner: 45 Fenwick Rd
Date of Inspection: 8—1 3—9 8 (If different) Newton MA 02468
Name of Inspector: WM E Robinson Sr
1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: WM E Robinson Septic Servi .p
Mailing Address: PO Box 1089 , C _n pr ui 1 1 oy MA 02632
Telephone Numbery 5 0 8` 7 7 S—R 7 7 6
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system: '
_✓Passes
_ Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails u
Inspector's Signature: ► Dater
The System Inspector shall submit a copy of this inspection 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:
!N 1 I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
C MMENTS:
B] S TEM CONDITIONALLY PASSES:
One or-more system components 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.
Indi a yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not.
_ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
(revised 04/25/97) Page 1 of 10
DEP on the World Wide Web: http:Nwww.magnet.state.ma.us/dep
j Printed on RegGed Paper —
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
s PART A
CERTIFICATION (continued)
' Property+Address: 107 Anchor Ln, Cotuit
r..
+ Owner: Rotstein
Date of Inspection:-`8—1 3-.9 8
,cBJ.SYSTEM'CONDITIONALLY PASSES (continued)
Sewa a backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
? — g P g
Pipe(s) or due.to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the
` Board of Health). Describe observations:
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
CJ FU HER 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) STEM WILL.FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
HE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
NVIRONMENT:
The system has a septic tank and soil absorption system (SAS) and the SAS 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 the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that
the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method used to determine distance (approximation not valid).
3) OTHER
(revised 04/25/97) Page 2 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 107 Anchor Ln, Cotuit
Owner: Rotstein
Date of Inspection: 8—1 3—9.8.
DJ. YSTEM FAILS:
You ust indicate ei;!;er "Yes" or "No" as to each of the following:
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.
Yes No
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool
Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2f 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 elevations
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.
EJ GE SYSTEM FAILS:
You must indicate either "Yes" or "No" as to each of the following:
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: .
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 Zone II of a
public water supply well)
The ner or operator of any such.system shall bring the system and facility into'full compliance with the groundwater treatment program
requir ents of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 04/25/57) Page 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 107 Anchor Ln, Cotuit
Owner: ROtstein
Date of Inspection: .8—1 3—9 8
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
Pumping information was provided by the owner, occupant, or 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.
As built plans have been obtained and examined. Note if they are not available with N/A.
y _ 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.
_ All system components, excluding the Soil Absorption System, have been located on the site.
_ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of
baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:—
The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of
/ Sub-Surface Disposal System.
t _ Existing information. Ex. Plan at B.O.H.
_ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) [15.302(3)(b)]
(revised 04/25/97) Page 4 of 10
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 107 Anchor Ln, Cotuit �a
Owner: RotSteiri
Date of Inspection: 8—1 3—9 8
FLOW CONDITIONS
RESIDENTIAL:
Design flow: �04 g.p.d./bedroom for S.A.S.
Number of bedrooms:
Number of current residents:
Garbage grinder (yes or no):_&-Q _
Laundry connected to system (Yes or no):
Seasonal use (yes or
Water meter readings, if available (last two (2) year usage (gpd): 1 996 - 63, 0 0 0 g
Sump Pump (yes or no): 1997 — 52, 000g
Last date of occupancy: 3^98�
COM ERCIAUINDUSTRIAL•
Type o establishment
Design T
w:_gallons/day
Grease tr present: (yes or no)_
Industrial ante Holding Tank present: (yes or no)_
Non-sanit ry waste discharged to the Title 5 system: (yes or no)_
Water me er readings, if available:
Last dat of occupancy:
OTHER: (Describe)
Last dat of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as part of inspection: (yes or.no) '3
If yes, volume pumped: /D "'Gallons
Reason for pumping: a i'/L
TYPE OVYSTEM
/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)
I/A Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGE of"all components, date•installed (if known) and source of information: t,-CA./
Sewage odors detected when arriving at the site: (yes or no) V
(revised 04/15/97) Page 5 of 10
r -
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued) 1
Property Address: 107 Anchor Ln, Cotuit
Owner: Rotstein
Date of Inspection: 8—1 3—9 8
BUIL ING SEWER:
(Locate n site plan)
Depth low grade:
Material f construction: _cast iron _40 PVC_other (explain)
Distance from private water supply well or suction line
Diamet
Comme ts: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK:_
(locate on ¢ite plan)
1
Depth below grade:
Material of construction: �ncrete _metal _Fiberglass _Polyethylene —other(explain)
If tank is metal, list age — Is age confirmed by Certificate of Compliance -(Yes/No)
Dimensions: 1
Sludge depth: 47
Distance from top of sludge to bottom of outlet tee or baffler
Scum thickness: 6 4
Distance from top of scum to top of outlet tee or baffle:_ t
Distance from bottom of scum to bottom of outlet tee or baffle:
How dimensions were determined: Gly, A— 7 A-
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of I' uid level in relation to outlet invert, structural
integrity,L✓ Ace of leakagegtc.) :•e d �e-• G-
GRE SE TRAP:
(locat on site plan)
Depth below grade:
Materi I of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain)
Dime sions:
Scum thickness:
Dist ce from top of scum to top of outlet tee or baffle:
Dis nce from bottom of scum to bottom of outlet tee or baffle:
D e of last pumping:
Co ents:
(reco mendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integ ity, evidence of leakage, etc.)
(revised 04/25/97) Page 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 107 Anchor Ln, Cotuit
Owner: Rotstein
Date of Inspection: 8-1 3—9 8
TI T OR HOLDING TANK: (Tank must be pumped prior-to, or at time, of inspection)
(loc_a on site plan) -
Depth low grade:
Mated of construction: _concrete _metal Fiberglass _Polyethylene —other(explain)
Dim sions:
Cap ity: gallons
Desig flow: gallons/day
Alarm evel: Alarm in working order—Yes; _No
Date o previous pumping:
Comm nts:
(condi ion of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX: 1�
(locate on site plan)
Depth of liquid level above outlet invert:__
Comments:
(note if level and ddistr ution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
PUM CHAMBER:_ .. ... �
(looat on site plan)
Pu sin working order: (Yes or No)
Ala ms in working order (Yes or No)
Co ments:
(not condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 04/25/97) Page 7 of 20
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 107 Anchor Ln, Cotuit
Owner: Rot s to i n
Date of Inspection: 8—1 3—9 8
SOIL ABSORPTION SYSTEM(SAS):_
(locate on site plan, if possible;_excavation not required, but may be approximated by non-intrusive 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:
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
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 construction:
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.)
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 04/25/97) Page 8 of 10
I •
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 107 Anchor Ln, Cotuit
Owner: Rotstein
Date of Inspection: 8—1 3—9 8
r
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
itA
c "1
1 - `
(r::vissd 04/25/97) Page 9 of 10
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a
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
I.
PART C
i SYSTEM. INFORMATION (continued)
! Property Address: 107 Anchor Ln, Cotuit `
Owner: ROtstein
Date of Inspection: 8—1 3 9 8
Depth to Groundwater Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
4
.Observation of Site (Abutting property, observation hole, basement sump etc.)
4
i Determine it from local conditions
Check,with local Board of health
Check FEMA Maps
t Check pumping records
Check local excavators, installers
Use USGS Data
Describe in ,yo M
your own words how you established the High Groundwater Elevation. ust be completed)
s /`"r/' j/FIB )
E
(revised 04/25/97) Paga 20 of 10
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
.....................OF...... e�Z
Allp irFation for DiipmFai Works Toutitrnrtiun ranfit
Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal
Syst _ � .................................................. ......r•.. ....................11..._ G... --- --•......................................
Qocati Ad&& t No.
J .................. ..................................... .......................................•
...-•-
r Address
.... ....
= ` - -- ...........................•--•-••--•---------•-..
Installer Address
Type of Building Size Lot_ .-&P ------- feet
V Dwelling—No. of Bedroom ._._..__ Expansion tic ( ) Garbage Grinder ( )
U 'Bg � ---- —
p`�,, Other—Type of Building V1 .....___ No. of persons.........;_____________ Showers ( ) Cafeteria ( )
a
� Other fixtures --------------------- ------------•--------------------------------------------------- -----------------•---------------••--------------.....--•----
W Design Flow..........S.3.........................gallons per person per�ay. Total d fly f)pw......... .....................gallons.
WSeptic Tank—Liquid capacity,/.X�.gallons Length ._. P ..... Width_ . .__ Diameter________________ Depth................
x Disposal Trench—No. .................... Width``_,_._......._.... Total Length..........._.... Total leaching area............ _.sq. ft.
Seepage Pit No---------�--------- Diameter.._.._ /__.__..... Depth below inlet....,7.3.._.. Total leaching area.,�f¢�__sq. ft.
Z Other Distribution box (r' ) Dosing tank,( )
0-4Percolation Test Results Performed by.......... . . _..._ .... Date___.t �� _+.�/........
W
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water______
fs, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-_VO... ...4 .�
Q+' -----------•------------------•----------------------------•---.....----••------•---•--•••-•-•-.............•---•-----------•------------•........•--...---•-
O Description of Soil ------ .� . -----
00
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 TITi U 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee issued by the boa d of health.
Signed--• . ...... . ........................... ..... .!-/-F17..Z.
Date
Application Approved By............. ... •• . --- ---•-•--•--------------- -•--- -
Date
Application Disapproved for the following reasons:......................................-----•---------...-------------------•-------------------•----...._.._...
..............•------------•••-----•---------------•-•----------------•-••--•-•.
Date
Permit No......................................................... Issued...... •- ,9 `-- � :.-.....
Date
7�C/
N —7�................ FEB
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF................................... ............ .............I......................................................................
Appfiration for Uispwial Works Tonstrurtion Prrutit
Applicationlis hereby made for a Permit to Construct X,or Repair an Individual Sewage Disposal
System at:
..................e2/............................................................. ....................z...................................................................e.........
L t No.
..................... .......
.................... ...............................................................................................
ddress
✓
.......... .........
Installer Address
PQ
U< Type of Building Size Lot_A)f_.6P_7-----Sq. feet
Dwelling—No. of Bedrooms--- Y13..........................Expansion Attic Garbage Grinder
Other—Type of Buildingh'W---------��j........ No. of persons--------- --------------- Showers Cafeteria
Otherfixtures ....................r�)...................................................... ......................................................................
Design Flow............ .....................gallons per person per,4ay. Total daily gow--------3,3......................gallons.
9 Septic Tank—Liquid capacityh�44�.gallons Lengthi.-Y...... Width..!5�.Yq.... Diameter................ Depth......._......_.
W Disposal Trench—No.................... Width............._._._.. Total Length_.........._____.._. Total leaching area....______.___.._..sq. ft.
Seepage Pit No........I---------- Diameter....._..___..._. Depth below inlet...71.'32 ...... Total leaching area.. q. f t.
Z Other Distribution box Dosing tank
Percolation Test Results Performed by.......... . .... Date...... X.
.............. ....................... ---
Test Pit No. I................minutes per inch Depth of Test Pit-_-___-_-.._.._...._ Depth to ground water...
LL, Test Pit No. 2................minutes per inch Depth of Test Pit____...._.......___. Depth to ground water.--'-,,
...........
.............................................................................................................................................................
0 Description of Soil................................................................. ... ;.........................................................................................
..............A.........3���
-------------------------*--------------------------------------------------- .........................................................................................
......................................................................................................................................................................................................
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'11 TIE 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.
Signed_ji,- J,-� _7116,e
........... I............................ ................................
Date
Application Approved By.._..__ I .e.
. .. .
Date
Application Disapproved for tie"
following reasons:................................................................................................................
............................. ..................... ...................................................................................................................................................
Date
Permit No.__._.. .. .. ........... ai Issued,.........................................................
... ................ ., -j ,
At
Date r
THE COMMONWEALTH OF MASSACHUSETTS
BOARD, OF HEALTH
..........................................OF......
. ........... ................................................................
(9rdifirati of (Ion''tpliatta
T411S IS T07CARTI-FY, Tat the Individual Sewage 'Disposal System constructed or Repaired
by -- ------- ........
............... ............................................................................................
-- ......*------------------- ........6 ..
stallerR
7- ..........111&V4
at----- .............. ..................... ........ ......................................................................
ye� .......jr............ ......
has been installed in accordance with<the provisions of T 5r.9iThe State Sanitary Code as described in the
application for:D,IsV,.osal Works Con'CERTIFICATE
s:iruction Permit N661---------- ...... dated---- ......
THE ISSUAACE OF TH I V"CE RTI F1 CATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SA.' TISFACTORY.—
"7 ....................... ...................................................................
j DATE........... Inspector-.,--.-.-'./
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
79
N ....... .............................. ..... .................................................................................... FEE..R 4......................
Disposal WorkiiTonstrurtion-famid
Permission is hereby granted......66. ,..G....64w....A..e.e.z...1......—... /..../1....4...o....4..-
.............................. ...............
to Consir6ct or Repair an Individual Sewage Disposa]IJSysteni
...........at No Cif.............. .........--------------------------------------- .............................j;-----------------------------------------------------------
Street
as shown on the application for Disposal Works Construction Pe. No____ ___ ted.... .........
------ ---- - -- -- -- ---
DATE.-- ..----71.?..................................... Board of Health"I
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
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