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HomeMy WebLinkAbout0108 COTUIT BAY DRIVE - Health ( 108 COTUIT BAY DRIVE COTUIT + A = 056 022 I } TOWN OF BARNSTABLE IL �/� {' v LOCATION SEWAGE # VILLAGE p ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. W A C 0 4q r P 9, t Al SEPTIC TANK CAPACITY LEACHING FACILITY: (type) /C°P ChW C IM (size) l^s NO. OF BEDROOMS BUILDER OR OWNE PERMTTDATE: ZZu COMPLIANCE DATE: 7✓9' 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 1 S R. No.R104-Y A- !��44 Fee-9 0, 0 0 THE COMMONWEALTH OF MASSACHUSETTS in computer. p Entered Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 2ppfication for 30iooml *r9tem Cotwtruction Permit Application for a Permit to Construct(A)Repair Upgrade( )Abandon( ) ❑Complete System ❑Individual Components , Location Address or Lot No. 108 Cotuit Bay Drive Owner's Name,Address and Tel.No.Peter McEachron Cotuit 108 Cotuit Bay Drive Cotuit Assessor's Map/Parcel `j 0 !2 4 2 0-8 2 7 3 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Joseph P. macomber & Son Inc Joseph P. macomber & Son Inc Box 66 Centerville 775-3338 Box 66 Centervill 775-3338 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 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, Loamy to fine sand Nature of Repairs or Alterations(Answer when applicable) Tnstallinq q_110�cultec Fdisposal Date last inspected: e/Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewa in accordance with the provisions of Title 5 of Fe,41 vironmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issuby this o . Signed Date _ Application Approved b Date Application Disapproved r the following reasons Permit No. 0 Date Issued r u z. r t °' ..A` � �"�'�• .,,.b.y„a,",F'x^ Jx.'n''at- cvu ,.i �ti �..- j - -. pm _ LQCATION ./� ... .. S) WACE':# VILLAGE ASSESSORS'MAP & LOB .DSG.-D2Z INSTALLER'S NAME&PHONE NO / M A '✓� P;P/�'� .�' S ,✓ ,�,;tr r,,, r SEPTIC TANK CAPACITY �,"a ad - -z''i LEACHING FACII.ITY:.(tyPe). (size) - NO.OF BEDROOMS— y c _ t BUILDER OR OWNS rQ ' ;; ,,:aFt ;:ref .::.-PERIvIITDATE Z Q: CbMPL'It1NC '`'DA"IE 7 "'<9 / ER111 f. I. Separation Distance Between the Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Pnvate Watdr Su ' 1 Well and Leachin Facili PP y g ty. (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leachin.`g Facility(If any"wetlands exist within 300.feet=of leaching.facility) Feet,. Furru�hed by ( 5 I f' Y y. i. ,. f f It I t ' ® ro ru s i d�, \ -------------- r �;1 '_ 4 J N �d a No.F,rs Lam+ A-- 7 W - M1 - Fee.5rk :!6 0 _ co THE COMMONWEALTH OF MASSACHUSETTS Entered°in computer: �✓✓/ Yes PUBLIC HEALTH DIVISION'-TOWN OF BARNSTABLEs MASSACHUSETTS ZIpplication for Oigooal *pgtem Conotruction'!Permit Application for a Permit to Construct(X)Repair(X )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 108 Cotuit Bay Drive Owner's Name,Address and Tel.No.Peter MCEachron ` QBtuit — �? 108 Cotuit Bay drive Cotuit t Assessor's Map/Parcel © � 6 Q 4 2 0—8 2 7 3 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Joseph P. macomber & Son Inc Joseph P. macomber & Son Inc Box 66 Centerville 775-3338 Box 66 Cemtervill 775-3338 Type of Building: Dwelling No.of Bedrooms Lot Size sift.. Garbage Grinder( ) Other Type of Building.-4— 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:Loamy to fine sand Vd 1 Nature of Repairs or Alterations(Answer when applicable) Insta 1 1 i nc 5-3 e ta1 taS. r -chagry-r V L 2 ` v Date last inspected: Agreement: rt 0 The undersigned agrees the construction and maintenance of the afore described o -site sewage disposal sys em in accordance with the prbyisions.of Title 5 of the nvironmental Code and not to place the system in operation until a Certifi- cate of Compliance has been tssu, ,by this-Bo' ' .of H alth. - - Signed i Date � z!� Application Approved b _ Date ' Application Disapproved r the following reasons Permit No. Date Issued 9" ._r4� �G THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance'' THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( X')Repaired( x )Upgraded( ) Abandoned( )by Joseph P,Macomber & Son Inc at 108 Cotuit DBy Drive Cotuit has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Penr&,N !1!�' dated JO'; k �� Installer J.P. Macomber & Son Inc DesignerJ.P, Macomber & Son Inc The issuance of this p shall not be construed as a guarantee that the syst ,. fund' n' ldesigne . Date Inspector 'C . r No. .�'���" � --------------—,-.,--- Fee 50.90 THE COMMONWEALTH OF MASSACHUSETTS ` PUBLIC HEALTH DIVISION - BARNSTABLEs MASSACHUSETTS ligogal *pgtem Conotruction,,permit Permission is hereby granted to Construct(x )Repair(K )Upgrade( )Abandon( ) System located at 108 Cotuit Bay Drive Cotuit 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/thi�s�rmit. Date: �� .�` � Approved45;; i�`TZg—a' � • l/6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only: CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) L ,Tc st- h P_Macnmhar Jr,; hereby certify that the application for disposal works construction permit signed-by me dated 6/28/01 concerning the property located at 108 Cotuit Bay Drive Cotuit meets all of the following criteria: • The failed stem is connected to a residential dwelling el t only,system g o y. 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. • There aie no wetlands within 100 feet of the proposed septic system F j • There are no privite.wells within 150 feet of the proposed septic system + There is no increase in IIow and/or change in use proposed t • There are no variances requested or needed. [ e I • The 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) • If the S.A.S. will be located,with 250 feet of any vegetated wetlands, the bottom of the proposed t leaching facility will nz be located less than fourteen(14) feet above the maximum adjusted ' groundwater table elevation, ' • r Please complete the following: 4 A) Top of Ground Surface Elevation(cuing GIs information), Z B) G.W. Elevation '�� +the MAX. High G.W.Adjustment. DIFFERENCE BETWEEN A and B A SIGNED : - DATE:- 6/28/01 (Sketc posed plan of system on backl. q:health folder ccn h i 5- 330 Cultec Rechargers Existing 1000 gallon leaching pit. New Distribution box Existing 1000 gallon septic tank. , A.M. 56-21 ` LOT 103 2' A.M. 56—08 188�9 N AREA=27,575fS.F. A.M. 56-22 N63 LOT 104 N LL�P „iiiiiiiiiiiii (F/VD) ,,,,,,,,,,,,,,, /o/ o U 0 ° ° 3-�/ A.M. 56—09 ell, ,,,,,,,,,,,,,,,,, POOL O ,,, ' 1 C , ,,, PAD CRA VRL DRIVE MVDJ �. LP LOT 105 41 (FND) A.M. 56-23 -`''- G-RAPHTC SCALE Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of �® Environmental Protectior WUNam F.Weld G 2 .� ' Trudy Coxe aowrrar Be-o-Y Ar�Paul Celluccl 0, Davld,B.Struhs LL e1D l � Camtnhdorisr rnor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FO PART A CERTIFICATION Property Address: Address of Owner. Date of Impaction: (If different) Name of Inspector. W.E. Robinson SR Company Name,Address and Telephone Number. ( 5 0 8 )7 7 5—8 7 7 6 W.E. Robinson Septic Service P.O. Box 1089 Centerville MA 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 sew disposal systems. The system: Y Passes Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails 1. n Ins tor's Signature: Date: "` 7 Pns f� �/v ) 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] 77have PASSES: not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 16.303. Any failure criteria not evaluated are indicated below. BY TEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. 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,cracked,structurally unsound, shows substantial infiltration or exfiltmtion,.or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a Fonforming septic tank as approved by the Board of Health. (revis 11/03/95) 1 One Winter Street a Boston,Massachusetts 02108 a FAX(617)556-1049 a Telephone(617)292-SM i�J Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:.�O �O�L2 C � ae— Owner. Date of Inspeotion: 2 B]SYSTEM CONDITIONALLY PASSES(continued) _ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(:) or due to a broken,settled or uneven distribution box. 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 paw inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed C] THER 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 free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or few than 5 ppm. 3) OTHER (revised 11/03/95) 2 L SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(oontinued) Property Addresw Owner. '/"t<-S �oltr/ �o6viCS�ry Date of Inspection: _ DI 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 his determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the 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 overlos ed 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 1/2 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. E)LAR SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: system serves a facility with a design flow of 10,000 gpd or greater(Imp System)and the system is a significant threat to public 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 H of a public water supply well) The owns or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program require to of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.. (revised 11/03/95) S. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: S` Jo/,-'7 �a GL fi f C- S vt Owner. M Date of Inspection: Check if the following have been done: Pumping information was requested of the owner,occupant, and Board of Health. one 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. facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow he site was inspected for signs of breakout. /All system components,excluding the Soil Absorption System, have been located on the site. _,t./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. 6 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. y The 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 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: ,4 8 C117�: i7- Owner. fir/✓`S 3r-a/7 rd Yej tL d/C- Date of Inspiection: FLOW CONDITIONS RESIDENTIAL• Design flow',33a canons Number of bedrooms: 3 Number of current residentaA Garbage grinder(,yes or no): � - Laundry connected to system(yes or no):-y- Seasonal use(yes or no): d Water meter readings,if available: Last date of occupancy: `� C'✓ COMMERCIAL INDUSTRIAL: Type o establishment: Design w:_gallona/day Grease ip present: (yes or no)_ Indust ' Waste Holding Tank present: (yes or no)_ Non waste discharged to the Title 5 system: (yes or no)_ Water r readings, if available: - Lest to of occupancy: •(Describe) - Last da of occupancy: . GENERAL INFORMATION PUMP G RECORDS and rce of information: A System pumpe4A part of inspection: (yes or no)_ If yes,volume pumped: ___gallons Reason for pump TYPE�SYSTEM I C✓ Septic tank/distnbution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes, attach previous inspection records, if any) Other(explain) APPROXIMATE AGE of all components,date installed(if known)and source of information: � 9� � a d d f, A. i�-? G o'a j yy Sewage odors detected when arriving at the site: (yea or no) 8 (revised 11/03/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: / O -S-- f,7 e c Owner. S y rJ Va Cf—4✓/C- Date of Inspection: -_2 >- SEPTIC TANK 1/ (locate on site plan) Depth below grade- Material of construction:_concrete_metal_FRP—other(explain) k , Dimensions: Sludge depth: ) ` Distance from top of sludge to bottom of outlet tee or baffle: 3 l Scum thickness:_ . I , 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.) /r/i 'S 1io �,, e L` GREA6E _ (locate on site lan) Depth below e: Material of co n:_concrete metal_FRP_other(explain) Dimensions: Scum Distance top of scum to top of outlet tee or bade: Distance from m of scum to bottom of outlet tee or baffle: Comments: (recommendation f r pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of etc.) (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner. rn r S \,7—e A -7 u vi c --i Date of Inspection: ,-2 TIGHT R HOLDING TANK_ Qocate on plan) Depth below Material of n:_concrete_metal_FRP—other(explain) Dimensions: Capacity: ons Design flow ¢allons/day Alarm 1 Comments: (condition of et tee,condition of alarm and float switches,etcJ DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet invert: Comments: / (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) V PUMP C BER_ (locate on plan) Pumps in rking order:(yes or no) Comments: (note 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: / C�7�Z c T- Dl- C'o Owner. /7 n �/'j aL j,if L S Date of Inspection: SOIL ABSORPTION SYSTEM(SAS):v (locate on eke 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: / Comments:(note Wndition of soil,e' of hydraylic failure, level o�ponding,condition of vegetation,etc. l D&--6lav/ CESS (locate on si plan) Number and co Lion: Depth-top of d to islet invert Depth of solids yer: Depth of scum yer: Dimensions of pool: Materials of co on: Indication of water: Mn (cesspool must be pumped as part of inspection) Comments:( condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc. PRIVY._ (locate on plan) Mate ' constriction: Dimensions: Depth of so' Conmenta: ote 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(oontinued) Property Address: �0 c<,;"-- /3✓ r f�� ���u C T Owner. Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' I 3� e; f S f • ill Qba� A B 3 DEPTH TO GROUNDWATER' Depth to groundwater, l I--I feet method of determination or approximation: K3 6.14 III , (revised 11/03/95) 9 THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) M AC DATA FEB,............................ ASSACHUSETTS HE TH .. ......... ............. ....................................... Applicati, or Repair an Individual Sewage zisposal Sys ............ -----------------------------­----- ......... -------------------------------- 0 - ---------------------------------------------- Location-Address or Lot No. ................ ................................................... ------------------------­------- 7T_._ 0 nor ddr wr-7ZI— A. P, fA .2 A IQ 4$X.......... ........ ..... .... . ... ................................................ 17... Q Installer 4 Address Type of BuildingI. Size Lot . .......Sq. feet U Dwelling—No. of Bedrooms...... ................................Expansiol Attic Garbage Grinder Other—Type of Building ............................ No. of persons.... ................... Showers Cafeteria Other xtures ................................................. ------------------ Design Flow...........41 ......gallons per person per day. Total daily flow...... ..............gallons. 9 Septic Tank—Liquid capacity) gallons Length................ Width--_---------_- Diameter..--..--.---.-_. Depth................ Disposal Trench—No-------------------- Width ....... Total Length Total leaching area sq. ft -------- --- , Seepage Pit No .)....... .....sq. ft. -----_-------- Diameter.._...-_�F------- Depth below inle ........... Total leaching area z Other Distribution box Dosing tank Percolation Test Results lo4 r Performed by..... Date-R-/, - 7d— r -------- ...............;G.0.P,3..IT J. ...minutes per inch Depth of Test P Test Pit No. L. Depth to ground water.._.............. ------ Test Pit No. 2................minutes per inch Depth of Test Pit..._............_... Depth to ground water........................ ---------_- ........................................................................................................................... Descriptionof Soil._. ..D.............(.)r.�Q.;.......=7::............................................................................................................ .................................................................................................................................................................................................... U . ........... --------------------------------------I............................ ........................................;...............................................:................ U Nature of-Zepairs or Alterations—Answer when applicable.....................................................................................0......... ..............................................................................................................................................................................................7......... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TI I T E 5 of the State Sanitary CoA —The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been ued by.the board of health. Dal­------------ S 1916 Si1ed..k_.(S\................................................................... .. ....... ApplicationApproved BY--- .... . . - . !�_7-------------------------------------- --------------------Dat-e-------------- Application Disapproved for the following reasons:................................................................................................................ ........................................................................................................................................................................................................ Date PermitNo........................... Issued....................................................... Date Noy.=r!..��`' .... Fx�. THE COMMONWEALTH OF MASSACHUSETTS BOARD 9F H TH ..... . ._. .....OF...... ... ..._.... ............ ................................ Appliration for Dhipmal ' aark,i Tomitrnrtiaan rrntit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal - s Sy M at: . lr --�— Location-Address. or Lot No. ...1 c...........:.. ..... -•----. ............ .................... .a......._'_:'I^.....-•-•-----------------._._............._ Owner " Ad'r Installer t Address QType of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms.__.._................:... .....Expansion Attic ( ) Garbage Grinder ( ) Other—T e of BuildingNo. of persons....... ................. Showers — Cafeteria a' Other fixtures ............. W Design Flow............. .Ie5l_................__gallons per person per day. Total daily ........................gallons. f:4 Septic Tank—Liquid capacity_. a.Ckallons Length................ Width---------------- Diameter___-____._____._ Depth_____.................. Disposal Trench—No. .................... Width....... _.......... Total Length.................... Total leaching area____.___._._..._....sq. ft. Seepage Pit No..................... Diameter................_... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank /f � � P 7oc- Percolation Test ResultsN Performed by Y..._______________ _______________________ Date____ Test Pit No. 1_____ _________minutes per inch Depth of ,Test Pit..../_............. Depth to ground water___10.0 (i Test Pit No. 2................minutes per inch Depth of Test Pit............_....... Depth to ground water........................ (� r O Description of Soil----1AW------ ? .........'" ----•---------•-•----••-=- W.. .-----------------------••......_. _ ..••-_.... •---••......----- ------...-----------•--------------------------------------•....._•••-------------....•-•_----••„----•..„.....•••. ----•------------------------ .........................................................------•---------------------------------------•---------------•-•........................................ 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 T ME )of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate'of,Compliance has been i sued the board of health. Ic n Signed.............. ... ......................................................... Date Application Approved By....... - _-- --------------------- ---------- 00r x, Date Application Disapproved for the following reasons------------- --------------••---------------------•-----------•---------------------------..---•-•--------••--„ ,#. _____________________________________________________________________________._._._.__....__.____.__._____________._.____.____________________.____..........__..._..._._.__. wr Date PermitNo :...........-------J = �r,f . Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD, OF HEAL „ r .OF . . ............. ...... Qurrfifiiatr of Taantpliianrr .. THLS IS 0 RTIFY, That the In(hyidual Sewage Disposal System constructed ( ) or Repaired ( ) r n, by.......... F�. ..... --------- at 11 ..------• _ d F �1-i!'-.. _oT. .............. 0_ r_! `'------•------•-------------------------- ----------- has been stalled in accordance withtthe provisions of'T- 5ppjhe State Sanitary Co re'. de ib lae 'application for Disposal Works Construction Permit No.......... dated___._.__.__................................... THE ISSUANCE OF THIS.CERTIFICATE SMALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM wiLL FUNCTION SATISFACTORY. DATE........................................ = Inspector THE COMMONWEALTH OF,MASSACHUSETTS BOARD OF _EALTTH 0, 44, OF....F .. �'......r........................... .a•� No....... FEE................. .. - r' tipli rk ., 11#rnrtion rangy# Permission i reby,granted•_....... "I ........................ 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