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HomeMy WebLinkAbout4527 FALMOUTH ROAD/RTE 28 - Health 4527 FALMOUTH ROAD,COTUIT A= 024 034 a f� I i I i COMMONWEALTH OF NIASSACHU,SETTS � I EXECUTIVE OFFtCE'OF ENVIRONMENZ A FAIR CE/VED 1; DEPARTMENT OF ENVIRONMENTAL PROT��T�'� 1S s8 ONE 1\-INTER STREET, BOSTON. NIA O'_108 61 7•39'�'�00 'n`✓NpFRA9Ns/tl� rI , ► • T R U D Y CO -\ WILLI.AM F.WELD API r �+ . �✓ Sectetan• . Govemo: DAV1D B.STRUHS ARGEO PAUL CELLUCCI ComQ�Ioner Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 2 J PART A CERTIFICATION 7 � Address of Owner: ° �E Property Address: YS a / '1 (If different) Date of Inspeclion:6-aC)-'?9 � Name of Inspector. ('Dl�lkRDl__ �dlJs=�C�(� 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15:000) Company•IVame: 6V;'tKi ..X isFI�LD Mailing Address: LZrOCO �dE *4 Oaf Telephone Number. CERTIFICATION STATEMENT address I certify that I have personally inspected the sewage disposal system rmed based and training information experie experiencereported the below accurate proper function and and complete as of the time of inspection. The inspection was perfo maintenance of on-site sewage disposal systems. The system: Y,. Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails S, Dale: y V Inspector's Signature: f Approving Authority within thirty (30) days of completing this The System Inspector shall submit a copy�f this inspection report to the App g 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: Checko 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�CMR i5.303. Any failure criteria not evaluated are indicated below. COMMENTS: B] SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass" paired. The system, upon Section need to be replaced or re completion of the replacement or repair, as approved by the Board of Health, will pass. f"not ain why not. Indicate yes, no, or not determined (Y, N, or ND): Describe bri of determination operator provided the 5 5temsinslpector with alc copy of alCertificate of _ The septic tank is metal, unless the owner o 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 ion if the existing septic tank is replaced with a conforming septic tank failure is imminent. The system will pass inspect as approved by the Board of Health. R Pago 1 of 10 (zevieed 04/25/97) . DEP on the World Wide Web hnp:llwww.magnet.state ma.usldep Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:cIV 7 Owner: {bPCbR(U CAaT"'1k1)Sf' Date of Inspection: T) B) SYSTEM CONDITIONALLY PASSES (continued) _ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructedof the pipe(s) or due to a broken, settled or uneven di stribution box. The system will pass inspection if(with approval Board of Health). Describe observations: r 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 pipets) are replaced obstruction is removed C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: n order to determine if the system is failing to protect the Conditions exist which require further evaluation by the Board of Health i public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES E E SYSTEM IS MENT:OT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE,PUBLIC HEALTH AND SAFETY AND THE _ 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 THE PUBLIC HEALTH AND SAFETY AND®HER�iINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT ENVIRONMENT: _ 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. I well. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply The system has a septic tank and soil absornd soil ption system and the SAS is less tion system and the SAS is hin 50 feet of a private than 1 0 feet but 50 feet ter or more from a _ The system has a septic tank volatile organic compounds indicates that Y private water supply well, unless a well water analysis for coliform bammon a nit ogen and nitrate nitrogen is equal to or resence of a the well is free from pollution from that facility and the p (approximation not valid). less than 5 ppm.. Method used to determine distance 3) OTHER page 2 of 10 (revised 04/25/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM . PART A CERTIFICATION (continued) Property Address: ySo�7 4�r.o�g Owner: RAC IRlu R oury TPUST Date of Inspection: —,�D —qg DJ SYSTEM FAILS: You must indicate either "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 112 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. EJ LARGE 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 11 of a public water supply well) t 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 04/25/97) Page 3 of 10 c r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:9 S.27 Owner: Pa PCOR N Rc,r4 LTy 7T USF Dale of Inspection: 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. _ 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, io , 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. 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 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner: POPCORN C:YdCTy I—jeo5T Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: g.p.d./bedroom for S.A.S. Number of bedrooms: Number of current residents:_ Garbage gr,r•der (yes or no):_ Laundry connected to system (yes or no):_ Seasonal use (yes or no):_ Water meter readings, if available (last two (2) year usage (gpd): Sump Pump (yes or no): Last date of occupancy: COMMERCI.AUINDUSTRIAL: Type of establishment: OFF(( SPgO� Design flow:_gallons/day Grease trap present: Ives or CO NO Industrial Waste Holding Tank present: (yes or(0�t_0 Non-sanitary waste discharged to the Title 5 system: (yes or i�Nfl Water meter readings, if available: Last date of o cupanc%: OTHER: (Describe) S('ICC caupic-0 Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: Rktr Of-EN IVMPCA0 System pumped as part of inspection: (yes or(o qLo If yes, volume pumped: gallons Reason for pumping TYP OF SYSTEM Septic lank/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: Sewage odors detected when arriving at the site: (yes or� NO (revised 04/25/97) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:g5,Z 7 OT M Owner: fbRoRtu Q4E4 7'V T(�UST Dale of Inspection: O_ 6� 9 BUILDING SEWER: (Locate on site plan) Depth below grade: Material of construction: _cast iron _40 PVC _other (explain) Distance from private water supply well or suction hi-4, Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK (locate on site plan) Depth below grade:/awc s Material of construction:&concrete _metal _Fiberglass _Polyethylene —other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance ___,(Yes,/No) Rtb° y r,nrrwK,�; ,r N Dimensions: V Sludge depth: 2 rN(NS '����S Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: NC q uuWS Distance from top of scum to top of outlet tee or baffle: 1 �f Distance from bottom of scum to bottom of outlet tee or baffle: le: f'rs How dimensions were determined: $') 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.) eP 5r f( ptlL TEES -TI�NK f N VARY Coop S f-lRP� ,V ep y ►7Tt9 SQL.fOJ GREASE TRAP: (locate on site plan) Depth below grade: Material of construction: `concrete _metal Fiberglass _Polyethylene ___other(explain) Dimensions: scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (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 04/25/97) Page 6 of 10 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 'W"?, Owner: POPaPAJ 12E9C ry Date of Inspection: 6 TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection) ' (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain) Dimensions: Capacity: gallons Design flow: gallons/dav Alarm level: Alarm in working order_ Yes; _ No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: _/ (locate on site plan) _ Depth of liquid level above outlet invert:ATAM M Of 6vTLE'T PrP� Comments: (note if level and distribution is equal, evidencg of solids carryover, evidence of leakage into or out of box, etc.) PIPE iN owE I r�oui PUMP CHAMBER:_ (locate on site plan) Pumps in working order: (Yes or No) Alarms in working order (Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (rovissd 04/25/97) Pago 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: K 7 RT 22 Owner: (b63C6Rru Po4iry 7-9or Date of Inspection:(�,aQ-y 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: ©A) S I k Fo o r /0QO 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 pf hydraulic failure, level of ponding, condition of vegetation, etc.) !�jr— y,r �s DR y O•�rG0 v ESN No or 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) Dimensions: Materials of construction: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, lition of vegetation, etc.) Page 0 of 10 (revised 01/25/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: RPCO(-tu 2EF►ZTY TQUSr Date of Inspection: 6 at7-q 8 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) �1 S (revised 04/25/97) - Page 9 0! 10 SUBSURFACE SEWAGE. DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:gs;7 Rf)8 Owner: Nocopl(! Reli t y TnUSr Date of Inspection:. 6 0�� Depth to Groundwater Q Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Describe in y M our own words how you established the High Groundwater Elevation. ust be completed) ro (;,06Uru0 WA U'9 rn/+PAW4 M14P (revised 04/25/97) raga 10 of 10 I _ _ YOU WISH TO OPEN A BUSINESS? For Your Information: Business Certificates.COST $30.00.for 4 years. A Business Certificate ONLY REGISTERS YOUR NAME in the Town (WHICH YOU MUST DO BY M.G.L. - it does not give you permission to.operate). You 'must first obtain the necessary signatures on this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, I" Fl.,.367 Main St., Hyannis, MA 02601(Town Hall) and get the Business Certificate that is required by law: Fill in please: DATE. �� < T APPLICANT'S YOUR NAME: BUSINESS YOUR HOME ADDRESS: L JS' Ili a 6� TELEPHONE # Hom TPIPphnnp t\I�Number: NAME OF NEW BUSINESY.cc � c C�iLip /.�C— TYPE OF BUSINESS IS THIS A HOME OCCUPAi ION? YES —, NOS Have you been �s /rLtJ�Y given approval from the building division? YES I�jO ADDRESS OF BUSINESS T T �OZ(o3 MAP/PARCEL NUMBER When starting anew business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. (corner of Yarmouth Rd. & Main Street) to make sure you have the. appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING COMMISSIONER'S OFFICE This individual has been informed of any permit requirements that pertain to this type of.business. Authorized Signature** COMMENTS: 2. BOARD OF HEALTH This individual ha .b inform of e pe t r. ements that pertain to this type of business. Authorized Wgnature** COMMENTS: A 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature** �' COMMENTS: ` t YOU WISH TO OPEN A.BUSINESS? For Your Information: Business Certificates cost $30.00 for 4 years. A Business Certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L. - it does not give you permission to operate.) Business Certificates,are available at the Town Clerk's Office, V FL., 367 Main Street, Hyannis, MA 02601 (Town Hall) Rn d 200 Main Street Offices at the Licensingcounter. DATE: Fill in please: APPLICANT'S a YOUR NAME: �13, BUSINESS YOUR HOME ADDRESS: �� �-� o� /2 r r C�dn edi- TELEPHONE # Home Telephone Number: s ad —Z �S -d�6 S� NAME OF NEW BUSINESS Ged r.e c,,-,A Mo, O�ch�e `�`^`� v'`� o-g`��"' °'��/ `e- E' IS THIS A HOME OCCUPATION? YES NO j TYPE OF BUSINESS_ K �-C 7` 7� Have you been given approval from the building division? YES NO ADDRESS OF.BUSINESS T -q- r- --A MAP/PARCEL NUMBER When starting a new business there are several things, you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST.GO TO 200 Main St. - (corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to le operate your business in this town. q Bally 1 . BUILDING COMMISSIONER'S OFFICE This individual has been informed of any permit requirements that pertain to this type of business. COMMENTS: Authorized Signature* 2. BOARD OF HEALTH This individual ee+in d ohe permit requirements that pertain to this type of business. Authorizture* COMMENTS: 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature* COMMENTS: TOWN OF B.kRNSTABLF. 0V LOCATION 7 �^`�'� SEWAGE # VILLAGE ASSESSOR'S MAP & LOT &-�3 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY' LEACHING FACILITY: (size) V0 NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: 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 byCsI� e- I. l' (A t F-7 Q L 0 CATION SEW E PERMIT NO. �' - 7 j VILLAGE t , INSTALLER'S NAME i ADDRESS VII, A -I A., S U I L D E R OR OWNER DATE PERMIT ISSUED d DATE COMPLIANCE ISSUED s° S va p� i Z ', \ 3 7ewN daod� R� �� ® n _ No................ 11 .-F�s....L..... .. THE COMMONWEALTH.OF MASSACHUSETTS BOAR® Of HEALTH ................r0l./h..--.--.OF......... ..' ..a... ........................................................ ApplirFation for 11ispnsal Workii T. nstrnrtiun runfit Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal System at: I )C� `f )3 (� ..... : . ..... ' ....... ". ' ... -� ........................ - -=- .-_..----- .:-- ..... , ocstion-/Address or Lot No. �c i....--•................................ ............................................. .. ss •••.•••• Installer� Address UType of Building Size Lot................Type feet �.., Dwelling—No. of Bedroom`�s..___}_r...............................Expansion Attic ( ) Garbage Grinder ( ) pa, Other -/Type of Building I - e!j�f- _ No. of persons............................ Showers ( ) — Cafeteria ( ) W Other fixtures ----•-.........-•-------------------------------------I. •-----•---•......................................... t.................. W Design Flow......................................... gallons per person per day. Total daily flow...........................................gallons. WSeptic Tank Liquid capacity/► gallons Length................ Width................ Diameter---------.-----. Depth................ x Disposal Trench—No......................Width.................... Total Length.....................Total leaching area....................sq. ft. Seepage Pit No........- ------- Diameter.......... ...... Depth,belo q. j® et- • ---------- Total 1 chi i� rea.X ---s ft. Z Other Distribution box ( ) Dosing tank ( ) �� 0-4 Percolation Test Results Performed by.......................................................................... Date........................................ 1.4 Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water-.--------.---.--.--.--. (14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water..--.--................. O Description-of Soil ...... ... .... 9�..... ----. .... .... ......... 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 TITL% 5 of the State Sanitary Code—The unders' ned further a s not to place the system in operation until a Certificate of Compliance has been issued b he b d It igned. .I...............•-•...... . --- .......... -.•---- ........... t Application Approved By------...... r° f(_:... 1 �1 . ----- ---... A� _/_` .9 ✓. -------- Date Application Disapproved for the following reasons:.............................................................................................................. ••...............•---•-.......---..__......-----....-----•---------------•-----•-•------... Date Permit No................................................................... Issued.42 a.7 -----•--------- -- Date ----•--•-•-----------------^ � No............... '.�FIZZ.... .w (r THE COMMONWEALTH OF MASSACHUSETTS BOARD Oq HEALTH -:' .............. ......-OF......... .. :.*Wl...........------------.......---••---.................. Appliration for Disposal Works Tonotrurtion ramit Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at oostion-Address or Lot No. .. �._ ........ ••------••••..........................6........................................................... y� � Owner Address a .........•... ....----lam;J>Lt cy- -------------------------------- ----- . ......................................--------- Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms/-I.... _ ...........................Expansion Attic ( ) Garbage Grinder ( ) aOther Type of Building ,, , '.. No. of persons............................ Showers ( ) — Cafgteria ( ) dOther fixtures -----------------------------------------------------•-••---•-•--•-••---••---•--•-------•--•--•-••--••-••....•--.... .........-------------------- W Desi n Flow. _...... ..?....._gallons. ._ ...................... gallons per person per day. Total daily flow............._:_._._... .. _ g •--•••••-- g P P P Y• Y iameter W Disposal Trench i u�do ca. ac>t Width ns Length Total Lengthldth---------------ToDtal leaching area Dept�n_._..__._....... Septicq P Y� -•----g g xea------•. - sq. ft. Seepage Pit No........I...........Diameter......../1..... Depth belo ' et..... i�_.._._.. Totaly11 chi /1 rea. .� .. sq. ft. Z Other Distribution box (; ) Dosing tank W Percolation Test Results Performed by......--;................................................................. Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Lt, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 04 , •---------------------------- ._._... -- ---. ------•- ••�--•---•---•-•-------------------•--•------•--...=--•=---...---------- Ox � � Description o Soil............. z- -- -.......--•--•---------- - ----44- - -----------------------------------------------------......_.._._......--- W ----•-------------------------------------------------------------------------------------------------------------------------------------------------------•-•-----•--•----------------................ U Nature of Repairs or Alterations—Answer when applicable............................................................................................... -•------------------------------•--------------------------------------•------------........----------------...--------------------------------------------------••----..........---•---- Agreement: The undersigned agrees to install. the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLL 5 of the State Sanitary Code—The unders' ned further a snot to place the system in operation until a Certificate of Compliance has been issued b he b d hAIt igned = ... • . •-•-•••- Application Approved By.. :-.. . t�6".!1.. . ............ 'Y t Date Application Disapproved for the following reasons:................................................................................................................ ---------------------- ............••.................•- Date PermitI4o.... ---.......---------------------------------------- Issued....................................................... Dale `so THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH s ........OF........... J1.............................................. Trrfifiratr of Tomplianr THIS IS TQ,CERTIFY That the Individual Sewage Disposal System constructed ( ) or Repaired by _.. r 5ra�; / -------- - ---. .1....................... at.. ..< �1 e,. ...lt� :YiI f1. -SP ✓ ----------------------------------- has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as descri ed in the application for`Disposal Works Construction Permit No----------------------------------------- dated.....�3.`. �'.. ................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE..... Z.2-!:._.. Inspector... .S :....v -_ -- ------ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............ . ......OF..----. !... ...`.................................................... �- No..............�� ... FEE......V Disposal Vork$ Cons W1 n annit Permission is hereby granted rT`........d. .................................................../................... to Constr ( ) o Repair ( �an Individual Sewa e/Dis al S s em at No..'.t.-.O—A,/-•--- i - ........ M Street as shown on the application for Disposal Works Construction Perm . o.... ed......................................... h ,.... ... ..... . -9--... ....... �j ,j �f�) ems' DAT+ V_ / f� P..................... Board of Health FORM 1255 HOBBS & WARREN. INC., PUBLISHERS - O No..........Z...... Flms.. .................. THE COMMONWEALTH OF MASSACHUUSETTS - ...... ... . OF.. ......... ................... ........ .�ppliration -for Uhipoiial Workii C omitrurtion Vanift Application"is hereby made for a Permit to Construct ( °') or Repair ( ) an Individual Sewage Disposal System at: --------------------------- Lotion-Address or Lot No. c C ` ;.1�:1►►�------ ----------------- ------c> --��°� ...... ' a Own Address ... _ ................. Installer Address QType of Building Size Lot___________________________Sq. feet U Dwelling—No. of Bedrooms-------------- -----Expansion Attic (� Garbage Grinder ( ) Other—Type of Buildin -01+� C S Q, YP g�- -- --- -------------- No. of ersons.--------.------------___--- bowers — Cafeteria Q' Other fixtures�__...__... W Design Flo all ons per person per day. Total daily flow_-_----_.- ..Gr (1- gallons. ... - -------- - - - -------- Septic Tan Liquid capacit - - .___-gallons Length................ Width_-------------- Dill eter.......--------- Depth----------_--- a Disposal Trench-'No. .................... Width........... _--�. ,ailenTo . leaching area-•--•---------------sq. tt. Seepage Pit Noamete`r`.—/ inlet.................... tal leaching area------------------ it. z Other Distribution box ( ) . Dosing tank ( ) Percolation Test Results Performed bY------------- ------------------------------------------------------------ Date-------------------------- -----------.. aTest Pit No: 1.................minutes per inch Depth of Test Pit-------------------- Depth to ground water.'_._.____..__-..____- �z, Test Pit No:'2___________ __minutes per incht De of Test Pit-------------------- Dept to ground water__-.-.-----.----__- t� ...._---- ------• ------ -- -•--- ---- --------------------- 0 Description of Soil �� Z�P e E,� = ------. - -- D -•-•-----•----------------------•--•---•------•------------------- -•--------------------- -•----••------------------------------------------------------------------------- ---------------•---------- ---------- --------------- 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 Article XI 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. ;.. ...--- ------- ----•---- Da Application Approved By........... .... %. . ........%,._ AW-, . Da e Application Disapproved for the following reasons-- -------------------------------- ---------------------------------------------------------------------------- -•-----------------------------------------------------------------------•---•------------------•---•---------------------•--.....-----------••-----••--•---•---------------------•--...------------ / Date PermitNo......................................................... Issued.--- f ---............. sy4 (r� No.---c''�' -..9'" FEs.p✓.................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HE T . ...... OF....Z.. ApVtiration fox igpnstt1 Works Towitrurtion Vrrmft i Application is hereby made for a Permit to Construct (") or Repair ( ) an Individual Sewage Disposal System at: L tion-Address or t No. a �'A-------------------- . ....................... ��._.�1. ................................ �. Own Address w �w.'�' - _�-±--�-`--------------------------- i .L'"f'.....•_�... "'y° `` ►��t-t Installer V17K Address Q Type of Building r. Size Lot-----------------------_....Sq. feet U Dwelling—No. of Bedrooms--------------- -----------------------`'.Expansion Attic Garbage Grinder ( ) p, Other—Type of Building-14/06%_4-------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Design Flo - � ---------allons per person- -------------------------------------------------------------=,��p ------ Other fixtures __.._._ w per day. Total daily flow..........-Al-!/_�`U__-_---.....gallons. WSeptic Tcln Liquid capacit�l �i"'____.gallons Length---------------- Width-.-...---.--_.. llia eter------.---_._... Depth--------------- x Disposal Trench—No. .................... Widtl en _ To leaching area----.-_--_-.__-.---sq. ft. Seepage Pit No.....�:___/ "ameter."' e o inlet.................... otal leaching area._-_-_____.,....sq. ft. z Other Distribution box ( Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date--------------------------------------- ,� Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water------------------------ r-14 Test Pit No. 2................minutes per incl� DeA of Test Pit----_............... Dept;to round water........................ ........... •••-• ----•------------•--- -- •..... -------- Oa.,.,..... �^. �. .,r Description of Soil. .._._... ------ ------- -•-----------------•-- z. .. ..... :_.. w ------- -- ----- U Nature of NZepairs or Alterations—Answer when applicable.-..-•-_-_-----_------------------•___.-.._------.----------.---.-------.--..._--.--.----..... ,. ------ ....:r----------------------------------------------------------------------- Agreement: , The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI 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. SigX;u,' .. ----------•-•------•-----------------------•--•-------•-- Dat�e� Application Approved BY n� - -- ------ a ----.... a1 Application Disapproved for the f olloiaiing reasons:................................................................................................................ H--------------------------------•---.---- ---- �_ � Date Permit No. _._... t Issued........ .:..._ -- ' - Date THE COMMONWEALTH OF MASSACHUSETTS BOARD 5,HEALT ` r Trrtif iratr of 601,11 plianrr TH I CERTIFY T the I ividual Sewage Disposal System constructed or Repaired- ,. f./ at - f j//� )�'' ) J' - - has be installed in accord with the provisions of Articl I The State Sanitary Code I- Is des i ibed in the application for Disposal Works Construction Permit No---------------- dated...._ `"'_...�. ............... THE ISSUANCE OF THIS CERTIFICATE SHALL. NOT BE CONSTRUE® AS A GUARANTEE 1HAT THE SYSTEM WILL/FUNC 1ON SATISFACTORY. DATE--- '' Inspector�..-- -------------------------- TH.:E COMMONWEALTH OF MASSACHUSETTS - . BOARD Of�F HEAL H � ........... ...... ..OF. iFJ . ...--.-- . .. `..---...T"--------- "W...►� No..... FEE ............. Dispo,itt IU k1l'TTn �ru . vik rrrnti Permission is hereby granted '"_.... ---- ""�% s_. ._ ( �" ................................ to Constr t ( , Repair f � a n g Dispo 1 Sy tem , Street as show on the application for Disposal Works Construction mit N : :_.. __ __ Dated.... s.._ !__........ ,f "` Bo rd of Heal DATE. c�.. � a FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS - .- i S t^aIT- Xt. - rG.'rl,it CGirCE� 3y_ ! n J tt--� -7 ( i i Ir Z uF,'!.;T C %e>tc4-. i lo � I } i � s � i � c44S_C.ia�- 1 11 t i li J FCt ow lac . _ . _. T- --___-----. - � ice_- {F i y E i it f. . I sl � S 4 ' f ♦4' ,.9�., lair �d,f C r....w:._. f � �� 1 may-�-- -�--- -..----------__-_ --T o r i t S 1 15.11 F464>04l4 2A. �g ----------------- �L I �