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HomeMy WebLinkAbout4556 FALMOUTH ROAD/RTE 28 - Health 4556 Falmouth Road/Rout-,28, Cotuit A= �� � � - Commonwealth of Massachusetts Executive Office of Enviromnental Affairs Dept. of Environmental Protection One winter Street Boston Ma. 02108 .Title Septic ' ' D.E.P. "Title V Septic Inspector P.O. Box 2119 Teaticke , A02536 WILLIAM RWELD 11 68,13 Governor ARGEO PAUL CELLUCCI ` U.Governor ^ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR. Jry'V PART A 'V CERTIFICATION 6 19 77CC f� Iv • 4i56 Rt. C�uit �� y�Ty��TTgBIF 98 `"�' lt Property Address. Address of Owner: Date of Inspection: 1/6/98 (If different) Name of Inspector: John Graci Sharon and Tony Fajao:810 Rt.149 Mars o ills 02648 C> 1 am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000) ` 9 Company Name,Address and Telephone Number: 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: X Passes This Inspection Is based on criteria defined In Title V code 31D CMR 16.303.My findings are of how the system is _ Conditionally Passes performing at the time of the inspection.My Inspection does _ Needs Furt r Ev ation By the Local Approving Authority not Imply any warranty or guarantee ofthelonge°ttycfthe F8115 septic system and any of Its components useful Igo. Inspector's Signature: Date: v6198 The System Inspector shall subm a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. 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: x I have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR 15.303. .Any failure criteria not evaluated are indicated below. COMMENTS: B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. Indicate yes,no, or not determined(Y, N,or ND). Describe basis of determination in all instances. If "not determined",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 CoMpllance(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 0427)97) .One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500 I R SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 4556 Rt.28 cotuit Owner: Sharon and Tony Fajao:810 Rt 149 Marstons Mills 02648 Date of Inspection:116199 _ Sewage backup or.breakout.or. hioh.static Water level observed.in.the distribution box is due to a broken. or obstructed pipe(s)or due to 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 leveled 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 C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply 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 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 presense of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method usedto determine distance (approximation not valid) 3)Other D] 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 in 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 cesspool. SAS is in hydraulic failure. (revleed 04r17)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) , Property Address: 4556 RL 28 Cotuit Owner: Sharon and Tony Fajao:810 RL 149 Marstons Mills 02648 Date of Inspection:116198 D]SYSTEM FAILS(continued) Yes No 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). Numbers 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 1 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] 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: 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 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 04127)87► SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 4550 RL 28 COtult Owner: Sharon and Tony Fajao:810 RL 149 Marston Mills 02648 Date of Inspection:116198 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: ,c_ _ Pumping information was requested of the owner,occupant,and Board of Health. x None of the system components have been pumped for at least two weeks and the 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. x As built plans have been obtained and examined. Note if they are not available with N/A. x The facility or dwelling was inspected for signs of sewage back-up. x The system does not receive non-sanitary or industrial waste flow. __ — The site was inspected for signs of breakout. x All system components,excluding the Soil Absorption System,have been located on the site. x 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. x 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 Systens. x Existing information. Ex. Plan at B.O.H. Determined in the field(if any failure criteria related to Part C is at issue,approximation of distance is x — — unacceptable)[15.302(3)(b)] (revised 04127197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 4558 Rt.28 Cotult Owner: Sharon and Tony Fajao:810 Rt.140 Marstons Mills 02648 Date of Inspectlon:116198 FLOW CONDITIONS RESIDENTIAL: Design flow: 2m g•p•d./bedroom for S.A.S. Number of bedrooms: a Number of current residents: 0 Garbage grinder(yes or no): No Laundry connected to system(yes or no): No Seasonal use(yes or no): No Water meter readings,if available:(last two(2)year usage(gpd): rda Sump Pump(yes or no): No Last date of occupancy: December COMMERCIAL/INDUSTRIAL: Type of establishment: nra Design flow:0 gallons/day Grease trap present: (yes or no) No Industrial Waste Holding Tank present:(yes or no) No-- Non-sanitary waste discharged to the Title 5 system:(yes or no) No Water meter readings,if available: nle Last date of occupancy: nra OTHER:(Describe) rda Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: Na System pumped as part of inspection: (yes or no)No If yes,volume pumped:0 gallons Reason for pumping: r0a TYPE OF SYSTEM Septic tank/distribution box/soil absorptions system x Single cesspool x 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 Information: 1960 Sewage odors detected when arriving at the site: (yes or no) No trevleed 04127197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 4550 Rt.2e cotuit Owner: Sharon and Tony Fa)ao:910 RL 149 Marstons Miles 02648 Date of Inspection:115199 SEPTIC TANK:_ (locate on site plan) Depth below grade: rda Material of construction:x concreate_m eta l_FRP_Polyethylene_other(explain) If tank is metal, list age o . Is age confirmed by Certificate of Compliance No (Yes/No) Dimensions: rda Sludge depth:rda Distance from top of sludge to bottom of outlet tee or baffle: rya Scum thickness:nla Distance from top of scum to top of outlet tee or baffle:rda Distance form bottom of scum to bottom of outlet tee or baffle: rda How dimensions were determined: rda 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.) Na GREASE TRAP: (locate on site plan) Depth below grade: rda Material of construction: _concrete_metal_FRP_Polyethylene_other(explain) Dimensions: nla Scum thickness:rva Distance from top of scum to top of outlet tee or baffle:nra Distance from bottom of scum to bottom of outlet tee or baffle:No Date of last pumping;v_ 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.) rda BUILDING SEWER: (Locate on site plan) Depth below grade: vs- Material of construction: cast iron_40 PVC other(explain) Distance from private water supply well or suction linetowr, Diameter: 4 Qmments:(conditions of joints,venting,evidence of leakage, etc.) ireyleed 04rt7l87) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 4555 RL 26 cotuit Owner: Sharon and Tony Fajao:810 RL 149 Marstons Mills 02648 Date of inspection:1f6199 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: rda Material of construction:_concrete_m eta l_FRP_Polyethylene_other(explain) Dimensions: nfe Capacity: nfa gallons Design flow: rda gallons/day Alarm level:_nfa Alarm in working order'?_Yes_No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) rda DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: nfa Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box etc.) rda PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no)No Alarms in working order(yes or no)_Yea Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) rda (revised 0477)871 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 4556 Rt.28 cotult Owner: Sharon and Tony Fajao:810 RL 149 Marstons Mills 02648 Date of Inspection:1/6198 SOIL ABSORPTION SYSTEM(SAS):x (locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: rVa Type: .leaching pits,number: 2 leaching chambers,number:ra leaching galleries,number: nla leaching trenches, number,length: nra leaching fields,number, dimensions:6x6 overflow cesspool,number:nla Alternate system: nra Name of Technology._nfa Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.) Overflows are aWcurally sound.They are empty. CESSPOOLS:x (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: nla Depth of solids layer: nla Depth of scum layer: nla Dimensions of cesspool: 6x6 Materials of construction: orangeburg Indication of groundwater: rda inflow(cesspool must be pumped as part of inspection) nla Comments:(note condition of soil,signs of hydraulic failure,level of ponding; condition of vegetation, etc.) . System Is structurally sound.System Is empty.Recommend pumping every two years. PRIVY:_ (locate on site plan) Materials of construction: Na Dimensions: rva Depth of solids: nra Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.) nts (revised 04127)87) r - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 4556 Rt.28 Cotult Sharon and Tony Fajao:$10 Rt.149 Marstons Mills 02049 1I0198 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) Page ! of 20 (revised 0MT19T) r y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 4556 RL 28 Cotult Sharon and Tony Fajao:810 Rt.149 Marstons Mills 02648 116199 Depth of groundwater 12. 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 X Use USGS Data Describe in your own words how you established the High Groundwater Elevation.(MUST be completed) USGS maps and charts s (revised04)2719T) 1629 10 0[ 10 YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates (cost$40.00 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.) 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, 1 st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is required by law. ..DD DATE: - .fo � ^ Fill in please: - � x la*"�� o APPLICANT'S YOUR NAME/S: W UM 4 ' rM; B SIN S OUR HOME—ADDRESS: c, m h TELEPHONE # Home Telephone Number ��_,. �- ,� . I C ea h ('4e-(;-q del,,`, i NAME OF CORPORATION: NAME OF NEW BUSINESS TYPE OF BUSINESS IS THIS A HOME OCCUP TION?_� ES NO � / ADDRESS OF BUSINESS MAP/PARCEL NUMBER .e (Assessing) 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 legally operate your business in this town. 1. BUILDING COMMISSIONER'S OFFICE This individual has been i formed of nj permit requirements that pertain to this type of business. MUST COMPLY WITH HOME OCCUPATION ULES AND REGULATIONS.-FAILURE TO Authbr igrnature* -C'^^ `'P MAY RESULT IN FINES. COMMENT Q I S i 2. BOARD IFALTH MUST COMP:Y:Vb' This individual has been informed of the j,�pqr' it e uir ments that pertain to this type of business. HAZARDOUS MATERIALS I.�_._. Authorized Signature**/ COMMENTS: 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) 1 This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature** COMMENTS: TOWN OF BARNSTABLE Date:10 /V7 TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAME OF BUSINESS: lu' AEoJT- 0,t C-0,Vj 10 QF- ,A2e. 1> BUSINESS LOCATION: kQ, TAi l.. op—rK It. INVENTORY MAILING ADDRESS: L5l'�,, ,E TOTAL AMOUNT: TELEPHONE NUMBER: 90Q - 4 CONTACT PERSON: ,10 A at,, n Fe 2L A EMERGENCY CONTACT TELEPHONE NUMBER: MSDS ON SITE? TYPE OF BUSINESS: GLENOWCs INFORMATION / RECOMMENDATIONS: Fire District: Waste Transportation: Last shipment of hazardous waste: Name of Hauler: Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more a month re uires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed / Maximum . Observed / Maximum Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive ❑ NEW ❑ USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides ❑ NEW ❑ USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED Miscellaneous petroleum products: grease, Photochemicals (Developer) lubricants, gear oil ❑ NEW ❑ USED - Degreasers for engines and metal Printing ink Degreasers for driveways&garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Miscellaneous Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt&roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (including carbon tetrachloride) ❑ NEW ❑ USED Any other products with "poison" labels (including chloroform,formaldehyde, Paint&varnish removers, deglossers hydrochloric acid, other acids) Miscellaneous. Flammables Other products not listed which you feel Floor&furniture strippers may be toxic or hazardous (please list): Metal polishes Laundry soil &stain removers (including bleach) hJ 0 L2 N 0 1-- 1T Spot removers&cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS PPlicant's Sig ature Staff's Initials LOCATION fc (9 3 SEWAGE N0. VILLAGE CQ' t12 t'r- INSTA LLER'S NAME i ADDRESS BUILDER OR OWNER DA T E P E R M I T I S S U E D %© DAT E COMPLIANCE ISSUED �� �� �. � � �P�t2 �f�sT�� /� '�S 1�� .� �.� �S � c �� � 4, ,-- - , � 1 1 ' �� .. � 7. �� � No. .:J� Fes$.....``?- THE COMMONWEALTH OF MASSACHUSETTS OAR® 0?9 HEALTH ..2_P ...OF........ . ... . /Y1. Appliration for Dhipoii al Vorkg Toustxnrtion Vanfit Application is hereby made fo Pe it to onstruct ( 41-lor Repair ( ) an Individual Sewage Disposal System'' at: ...�1X..s .. dr�..s.. y.... ».. ................. .................................... ..._.....................---.............. / oc 'o dress or Lot No. .........5./.... .....4--L .... .:.:..................................: .........................................................................................»..... WOvfidr Address a ..... _------------------------------- ..................................................................................................----------••-•------...............•-----.........................................------------••-- nstaller Address d Type of Build in °~�' Size Lot............................Sq. feet Dwelling{%o. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) �a Other—T e of Building yp ,. g ............................'No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures ------------------------•----------............... .---------------- •------•--•-•----.---- 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 below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) 0-4 Percolation Test Results Performed by.................. Date...........>............................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................•.. Depth to ground water........................ 0 Description of Soil......................................................................................................................................................................... x -------------------------------------------•------------------------•------------------•----------------------------------------------•- •-••-•---- ------------------------ AP�, U Nature of Repairs or lterati s— nswe h applicable.---- /'_�.$� _ d-. � ��� } Agreement: �/ The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITIL 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 ----------------- ----------- ' _Date Application Approved By........ -. ._ - -_-•-- /� - ... --Date .... Application Disapproved for the following reasons----- .............. ------------ --- ......................................................... ...............•----........-•-------•--...------....._•----.......--------•------•--•--•----•-----••-•--••-•-••--••--•-----•-----•••••----•---------••----••---•-•••--•---•••-•------••••••-----.....-- Date PermitNo......................................................... Issued..... --- ...................» Date No. . .....�... ... . § FRs..... ~.--- THE COMMONWEALTH OF MASSACHUSETTS n OARD OF, HEALTH 1 ,. Appliration for UiipIIiial Works C onarurtion ramd Application is hereby made f Pe mit to" onstruct ( 41'or Repair ( ) an Individual Sewage Disposal System at: / �, ^� ................ . _. F�l.:. L: ..... -----.._....-----•.......................... •-•••----............._.................. "Loco Tess or Lot No. •- .. .. ................... ............................... Address a _...�rE-tr.�._.I":CSC:!.-•-•- •- ---.....c............................... -----._.....----•--...-----•-•---...-•----.....---•---•-••------...-•----._..._..._.......---•-•-• Installer Address "` S feet� Type of Buildin� ;� q. U Dwelling-4VNo. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type,of Building No. of persons............................ Showers — Cafeteria 04 04 Other fixtures -----•------ ----------------•----•--••-••--•---.....----------•-•-•----•--••••-••-•-----•-•----------•----------------------•-•-------------------- 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 below inlet.................... Total leaching area..................sq. ft. . Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ --•------•------------------------••---.....----.....--•---•--------._....--•----------•....._-•----......................................................... 0 Description of Soil........................................................................................................................................................................ x U ----•--------------•--•-.-----------------•-----------------------------------------------------------•---------------------•-----•----------------------------••--------------- W •----•-•--------•--•--•---------------------•-•••-•-------••-•-------••----••-----•------------••--------•-•---------- ` U Nature of Repairs r lterati ris—Answe Vhn applicable____"'....!.`.. � Z, ... . ...._ __. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TI=- 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. S. •--f- • ._..... .............................................................. .......................... Application Approved By---... - � .._... ° "�'zl��° - '` .r l..Y f Da .:..... �� I Date Application Disappi.oved for the following reasons:................................................................................................................ ........................... •w= ..............--•-----------•------••---•-------•--••-------------------------------------------•----------------------------•-•--•---------------- Date PermitNo......................................................... Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD Of HEALTH ..... ............O F...........:........ .........e........................................... f9rdif iratr of Toutpliattrr y, THI O,CERTIFY hat the Individual Sewage Disposal System constructed ( ) or Repaired ( ) ._ by a�.� ..... .... - ----•--- at.........._t !' ..._C H/`L�V............ �-✓ n---- ............................................. !<y4 _' has been installed in accordance with the provisions of T '��, 5 ,of The State Sanitary C de as described 'n the application for Disposal Works Construction Permit No. ) --- - dated... --- -/j �_~ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE..............•--••----....-•--•-----............--...-----•-•---•----•._...... Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD F HEALTH t .....`........... FEE.......... .......... �i rr orki TJZ. t uan rrmit p Permission is hereby granted_ _. �. .� ' a�.... .1 �_. .. .....:.. ...to Constru ( or/gtep ' (!an Individual Sewagl Sys'/ G atNo. .__..... .............................. .............................................. St et as shown on the application'for Disposal Works Construction P-r it N .__. ma Dated...... ...... -' . ..... .... ..�............. -----------------------------. Board of Health�� DATE..........--[%------•-G---------................................................. FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS .y f L O CATION S E W A G"E N O. VILLAGE INSTA LLER'S NAME i ADDRESS BUILDER OR OWNER . 1 DATE PERMIT ISSUED � I DATE COMPLIANCE ISSUED //v/Ro f I s j r 6