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HomeMy WebLinkAbout0150 HIGHLAND AVENUE - Health 150 HIGHLAND AVENUE, COTUIT :(Coo py� Commonwealth of Massachusetts ( Executive Office of Environmental Affairs -- Department of Environmental Prot iiian, %Mill= F.Weld �` TrudyCc" a DEC 1 (� �y�v Argeo Paul Gllucel Secrutary -. David S.Struhs Lt cioNen« 1 i A11N i�"a commismonaw SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECLION�-{FORM +¢� PART A ` (L 2� CERTIFICATION Property Address: 15 0 H i land Ave. C O t u i t Address of Owner: Date of Inspection:9/19 96 (If different) Name of Inspector:F r e d e c k K i e 1 y Company Name,Address and Telephone Number: Environmental Reclamation Inc. 446 Waquoit Hwy. CERTIFICATION STAf&JR I t MA 02536 1 certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: Date: The System Inspector shall submit a copy of this ins on report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C,or D: A] SYSTEM PASSES: XXXX I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. 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, 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 11/03/9s) One Wlrtter Street 9 Boston,Massachusetts 02108 9 FAX(617)556-1049 9 Telephone(617)292-594o A 4,Pnnted on Recycled Paper J SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: BI 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(s) 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 pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed CI FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone'I of a public water supply well. _ The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. 3) OTHER (revined.11/03/95) 2 r F SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner. Date of Inspection: 131 SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 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 i analysis. If the well has been analyzed to be acceptable, attach co of well water analysis for acceptable water quality a ys y p PY Ys+ coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E1 LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: the system is within 400 feet of a surface drinking water supply _ the system is within 200 feet of a tributary to a surface drinking water supply k x _ the system isjokated in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone Il of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment.program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (• (revised 11/03/95) 3 SUBSURFACE SEWACE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner. Date of.Inspection: Check if the following have been done: Pumping information was requested of the owner, occupant, and Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving nominal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. N 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, excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles of." tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. 2The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. 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: Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: srallons Number of bedrooms: Number of current residents:L Garbage grinder (yes or no):�D Laundry connected to system (yes or no): Seasonal use (yes or no): Al Water meter readings, if available: Last date of occupancy: COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: aallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: '.ast date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no)A If yes, volume pumped: gallons Reason for pumping: TYKE OF SYSTEM Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Other(explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: 2C MAPS COIUST 8f�jcr Sewage odors detected when arriving at the site: (yes or no) (revised 11/03/95) 5 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 15-Z> H I&Nlrl,Db Owner. Date of Inspection: Q1I1lgQ SEPTIC TANK:—( (locate on site plan) Depth below grade: Material of construction: 4concrete _metal _FRP _other(explain) Dimensions: Sludge depth:_ Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: (p Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: s Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, integrity, evidence of leakage, etc) GREASE P: (locate?site plan) Depth below grade: Material of construction: _concrete _metal _FRP —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: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, strut integrity, evidence of leakage, etc) (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: TIGHT TANK:_ (locate #OLDING plan) Depth below grade: Material of construction: _concrete _metal _FRP—other(explain) Dimensions: Capacity: ttallons Design flow: aallons/day Alarm level: 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: Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage.into or out of box, etc.) PUMP BER:_ (locate ite plan) Pumps in wort I order.(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) `. (revised 11/03/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection:SOIL / ABSORPTION SYSTEM (SAS): V (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, numb er:�-. ea in ambers;number._ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) CESSP _ (locate7 .e�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.) P _ (I a on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition-of vegetation, etc.) (revised.11/03/95) 8 CI I e SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ( SYSTEM INFORMATION (continued) Property Address: 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' .SINGLE �AMT_L DWELLING 150 HIGHLAND AVE. COTUIT MA I i \ I I � ►4.9 l8 \I O TANK i i I i D-SOX i I i f SA S i j 1 DEPTH TO GROUNDWATER i Depth to groundwater. AC) feet method of determination or approximation: Su R FRCZ (.J R')C R E 1 EV)4 TI ON O_1F LEWIS PO!U h C.QM?11IPt1b TO CITE- EA V4T/nnJ AS CHo RAJ dN hTu/T' QURb l.S�' (revised 11/03/95) 9 ,, .LOC,QT IOKI ' 5E)N CAE PERMIT MO. VILLAGE - C..,� WSTQLLER• , U&ME ADDRESS BUILDERS tJ &ViF- ADDRESS j�eGf'mr�H DATE PER"lT ISSUED DATE COMPLI &MCE ISSUED : �, �� i '7, No..----.....:S.f.... Fss.... J_ THE COMMONWEALTH OF MASSACHUSET'FS BOAR® OF HEALTH a 1 ............ .OF.....�. rt '..... Appliration for Disposal Works Tnnstrnrtiun Vrrmit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal .System ak �� ..� .� _ Location ddr ss or Lot No. •—~ .. ... ...................... er Ad__d_r__e`ss ddres . ...: ---------------•-- :d Type of Building Size Lot----------------------------Sq. feet U Dwelling�No. of Bedrooms........... ............•...............Ex Expansion Attic �,�.• � � g— � p ( ) Garbage Grinder K��) Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures -------------------------------------------•----------••------•-•-•---------•.....---•---•-•--••--•••-•---------------•--•---------•-•--•--....------ W Design 'Flow........-... ............gallons per person per day. Total daily flow....... ....................gallons. WSeptic Tank L Liquid capacity............gallons Length................ Width................ Diameter---------.----.- Depth................ x . Disposal€Trench—No..................... Width....... ... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No---------/--------- Diameter.. epth below inleeL. Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing to ) � G Percolation Test Results Performed by--•-••..V�1�C -r_ � 7 7 .a ------•----------- Date----- ---- ----- Test Pit No. 1................minutes per inch Depth of Test Pit.-----.............. Depth to ground water..--...--............--. fL, Test Pit No. 2................minutes per inch Depth of Test Pit..--................ Depth to ground water.....................--- 1 O 1Descripton of Soil............. �-- �' _ � — �..--.-- •---� -�-- - ----�G� -- �- v = ---------------------------------•-----------------------------------------------------------•------------ ----------------------•------------------------ W ---••-----•---------- ---- -=-=-------------------=------ (`U Nature of Repairs,or''Alterations—Answer when applicable................................................................................................ -•------•--•--••-••-•-•----•--•••------• ---•---------------------------------•---•-•••--••••----••- . Agreement: k' The undersigned agrees'to install the of descri ed Individual Sewage Disposal System in ac ordance with the provisions of iITLi; 5 of the'State-Saiii ry Co The undersigrrd further agrees not to place he system in operation until a Certificate of Compliance s e y th ndo h Sign .......---- ...... 2 --- ...................... da Date Application Approved By....... ---•- Date t" Application Disapproved for the following reasons:................................................................................................................ ' Date Permit No.................... ......------•----•------...... Issued....q'"�l `7� -- -- ------•-------- Date No .... Fimic ................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH , .............. OF....&4+- -*..........................7................................... Appliration for 11hipasal Works T-Vulitrurtionramit Application is hereby made for a Permit to Construct or Repair an Individual 'Sewage Disposal system .......... .. ... . ....... ------------------------------------------- Locatio -Add ss or Lot No. Ad---_-------------- -----------------------------------............... ... ........ ................................ .... per ........ Address ........... ........................................ ............................................. ................................................... Installer Address Type of Building Size Lot___________________________Sq- f t Dwellinge7No. of Bedrooms-___i-3.............................Expansion Attic Garbage Grinder ) PL4 Qther,—Type of, Building ............................ No. of persons:.___________._______.__.__. Showers Cafeteria Other fixtures .................... . ......................................................................... 0 ------------------------ Design Flow .......#�..............gili s per person per day ,J�b Rf�daily flow-.____;3 Z A..................___ gallons. gallnS.' Y-­ 9 Septic Tank Liquid capacity............gallons, Length................ Width__._ Diameter......_.__-_____ Depth_.__. Disposal Trench 'N Width Total Length.._________............Total leaching area....................sq. f t. ...... ot ...........&-a-in- eter. 441epth belo .......,Tl *1chi r area..................sq. ft. Seepage Pit No- -- --------- Tg Other Distribution box Dosing tativ., 77 Z �_4 1 Performed Percolation Test Results by.-.7_40,�w4o, ;Am. ................. Date_.__ .77.�. .... ....... ........ Test Pit No. I.......... --minutes per inch Depth of Test Pit.................... Depth to ground water...___...._.________._.. Test Pit No. 2..................minutesper inch Depth of Test Pit_.____......_____.__ Depth to ground water.._ Pi' ........................ . ............ ..... ..... ...... 0 ....Description of Soil ......L.4 ............ ... ........ ... ......... . .. .........0. . ./��......�. .....................I............................. -------------------7---------------------- -------------*--------------------------------------- -------------*................ -------------------------------------------------..................................................................................................................................................... U Nature of Repairs or Alterations—Answer when applicable--------------------------------------------- .....................................4............. .........................................................................................................................7............................................................................ Agreement: The undersigned agrees to install the of e'escAed Individual Sewage Disposal System in a ordance with the provisions of T I T 11 5 of the State San' ary Co The undersigiked further-agrees not to place the system in operation until a Certificate of Compliance a eee y the-bQard o li th Signe .......... ... .......... e ...... .............................. lat Application Approved By-------- .,,r... ... ... .... ..... .4-4. .. .. ..!.. ...... Date Application Disapproved for the following reasons:...........................................................................I ............................ ........................................................................................................................................................................................................ Date PermitNo......................................................... Issued........................... ................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF_, EALTH ..... . .... ...................................... . ... Tatifiratr of 6mpfianrr T S HISS TOCE IFY at the Individual Sewage Disposal System constructed or Repaired by..... or-im....... .. ....... ....... installe A................ ...... .............0 i......... ------------ ------- 07 'o...... at...... ;;Ap.jp... ............... ........ has beeft installed in accordance with the provisions of T Z� 0 The State Sanitary Code. as described in the application for Disposal Works Construction Permit Nou J�i- ......... 7.............. dated.....7!_'.A 7------------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEK-WILL*FUNCTION SATISFACTORY. DATE....................................................I............................ Inspector........_.__...----------------- ................................. .p ,................................................ THE COMMONWEALTH OF MASSACHUSETTS BOARD F HEALTH .......... .........................OF......;Aro.... ...................................................... No... ....... ............. PermPermission ereby granted____.. . . . .. ........ ....................................................................... ..... ............ to Const I iv dual Sewag.� Dispggal Syst or e air 4��V r aw I _; ... at No...... *�.'I.�p ......v .." . .... I, ............. ................. ...... .. ........... Street as shown on the application for Disposal Works Construction Permit Date d,7,,--1 J�- :17 ..................................... Board of Health T......... DATE---- --- ........................................................... FORM 1255 HOBBS,&.WARREN. INC., PUBLISHERS 1 z� T. A NIS\ `V X/ 3J., i ? yff,� `Q ;V y •do %N .A 2-/;40 DsFy cp co { F r TESTS t9 V a I C J - ,'�,, , ' � �:,,�_� • ,t'�f art . 0A 4-7) CERTIFIED PLOT -PLAN - ., LOT Z EX?. CO7—/7- NEW CONSTRUCTION ONLY _ TOP--OF� FOUNDATION IS i FEET IN ABOVE LOW POINT •OF ADJACENT ROAD,- SCALE: /LN._qo FrDATE:.,IvL 2.7,/9 77 ELDREDGE ENG/NEER/NG: CO.1N _ [,'CERTIFY THAT THE Fou4PAr,oN EQLSTE E REGISTERED CLIENT SHOWN ON THIS PLAN IS LOCATED CIVIL LAND JOB NO. •77O ON THE GROUND AS INDICATED.A N.I7 p ,ENGINEER SURVEYOR DR.BY: ` C,0NF0 RMS TO T•HE Z0N- G W.I;N, .LAS _ P'F_C3ARNS BCC, S. 33 NO. MAIN ST 712 MAIN ST CH. By: R'r' $• 7/7/ ` SO..YARMOUTH, MASS: HYANNIS:, -MASS. SHEET- OF Z DATE REB. LAND N SURVEYOR 20 FT. M//V. /O Pr. 1W/N. CONCRr'TE 9 0RVC- PIPE CLEAN SAND EL�Y. Ioo:t� COVERS M/N. fs/TGN CO^N CJPET.E i A ,Q• /od /— CpiiER � a L/QUID LEVEL / d 4" C.1ST * ,c..1, 2"LAYER o- M/N.PircN GAI.. e • • • s , ' p oAc ' %� Pt/r —r SEPTIC TANK D/ST. 0 c � • • • . . . 1-1 � , r ° {'VASHFD 57?7NE � aox _ • P ap o 1 1 •EFFECT/VE ► ' , •y 314 o.. o o , • • DEPTt/ • 1 ►' • v o 1✓ASl/ED STaNE is O , • • • ♦ • • p n r ° , • . e • _ . • . , pa p PRECAS T SEEPAGE !A/VC97 C'�C EYAT/DNS d • r 1 • • • • • • , ' pa a a jo P/7 OR EQU/V, 4 /NYERT AT BU//-DING -7 © FT. 6 INLET SEPTIC TANK 96,6 FT —L_ FT, O/AM. k C SEE TWVl_ATJON, OUTLET SEP7/.0 TANK 9G•6 FT. f( //V,GET D/STR/BUT/DN BOX 9 6 4 FT, SECT/ON O F GROUND W,4 reR TABLE Ot/TLETD/STRIB/JT/ON BOX `3'b.3 -FT. - � /NLETSEEPACiE PIT ,fib, U Fr S�NIAGE .DISPOSAL. SYSTEM LEACH//VCw o/T , ?ABULATlON DES/GN CR/TER/A SCALE : %s" _ /R-,o" OJNJENS/ON A FT. L3/MIENS/oN $ FT. NLIM&ER OF BEDROOM,, 3 Gr'�R!$AOE DISPOSAL UNIT_ TOTAL, EST/MA7.-D F'Low 3 t7 0o s. c./oA�✓ SD/L TEST /VUM8,ER OF SEEPAGE' A/T5_ . t SIDE'LEACHI/VG PEi7 PIT l B Sq. �T SD/L LOG ,DATE OF SOIL TEST 90TTOM tE,ACN/NG ALLR PIT 7S TEST P/T IfE L TE$T PI 7-#i2 ,RES/JL75 N/ITNESSEL� BY. - x FT ELEi�AT/pN PERCOLAT/ON RATE M/M�IINGH TOTAG,7 LEACH/NG AREA Z-64- Sq ITT. � RE3ERYE LEAr CH!/Vcs AREA SQ. F T. f { 2 ON F/Lr= 1/Y i 7-)4 �*�tN OF 0tj 0 M�s S AR►J.S'1`.a t3 L R�D/v/ `z ' ! Lo 2- 0.4-R D G1 F' T RO�ER7 ^� n )y L.�- H/cam L�NIJS R0.) SA7" C)rd•T- $UNIKIS in a S �/ 9o�No 22162,0 o ji b U�ST�W �L EiORZPCVZEN&JmeER/NG C-0,/NC. rJ1 fifrs'ONAL�.e" 712 Mr91/Y'S7'. 3.3 IWO.MA11V ST ° rir1� HYANIVII, MA55, SD. Y,4/P/ 04.1TH M.4Ss a ✓oa No. -'7 0 3 sHEZT oF- 2- No......�Iih..... Fimic.............................. THE COMMONWEALTH OF MASSACHUSETTS �d BOARD OF HEALTH o.� Appliration for Ropmal Works Tonotrurti n rrmit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at: 60,fA6_,' . � ,/ Ae�se�c7O Location-Address or Lot No. ..............- - ' . t:: * C/' giro... --- --------------------!G .s 0'-z1X7 ...Q0o©,f.... 0 Address Installer Address d Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms......;,�----------------------------------Expansion Attic ( ) Garbage Grinder ( ) p, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Pa Other fixtures ............................... W -Design Flow............. . ................. .gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity �D�gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No......... .....__ Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No./P.0.0........ larneter____________________ Depth below inlet.................... Total leaching area..................sq. ft. 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........................ (i Test Pit No. 2................minutes per inch Depth of Test Pit.................•.. Depth to ground water........................ •---•....• •-••-•..--------••••--•-•--•--------------------------------------- -- ---- .._..........•------------ ---------------.----- - ODescription of Soil..............✓ ! .-.---••-•---•---------...........--•-•-•---•-----------------------------------------------------------------------------------------•-. V --------------------------------------------------------------•----........---•----......------......-----•--------------•-•----•--.........._........_....----.......-_............................---- 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 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. V Signed..... .._.1/l = ................ ................................ /� �... Date Application Approved BY �._ ......---..�!��lL /u-� �'�' !/� �! 7 / d Date Application Disapproved for;4 following reasons: ----••-•-•-•-------•---•......------•-•-•------------------------••----•---------•._........-•-•--......-••••-••••-----•-----•--•••------•------------------------------------------ .............. Date PermitNo......%.I.- ... -------------------------------------- Issued........................................................ Date No.---- FEE..................... .... THE COMMONWEALTH OF MASSACHUSETTS - �� : BOARD OF HEALTH ,... ......... ... - ,P�j firation for Dispotia1 Works Tongtrfir�Vn Vrrmit Application is hereby made for a .Permit to Construct;. or Repair ( ) an` Individual.Sewage Disposal System at: C 4*Ar-iI : � C•► �' • w / 4C.4& -------------------- ...................... Locatron-„Address �r + `k or Lot No. A ,..: J�rt ." r+tY, iK 6 4 e'`+:.LQ e6.e"Jf J'" • C: t�G' .... ............_ .. --:�....--•- -•-..... -•------------•• • -• •-•-•--- --------- ---I.. .................................... Owner Address a / G 'r ------/ ' -------•-•-------•----------•----- ---....... ....... --- ...--••-•--•---• ---••---•---_.... � Installer Addreesss s ,. Type of Building Size Lot________________ S feet U �Iw q I, a Dwelling-No. of Bedrooms { __.__ Expansion Attic ( ) Garbage Grinder ( ) p, Other Type'of Building.y Na 'o# :persons: Showers ) — Cafeteria a ( ( ) r Other u es -- -•- ----- ------- <: W Design Flow'.._r s :_________ _____4Fgallons.per" person per day. Total daily 'flow_____._ __.................................gallons. ' 1x Septic Tank—Liquid capaaitx��Pgallons Length_________________Width .__._..._.__.. Diameter................ Depth................ i Disposal Tretzeh Na �" Widtlt ;.___:_.____._._._ Total Length____________________ Total leaching area________._....._..__s ft. 1' ,0._ b g sq. No/4010_______ Diameter ______________ Depth below inlet.................... Total leaching area...................sq. ft. Z Other Distribution box ( ) .�t, Dosing tank,-(,., ) . Percolation Test Results Performed by------------- Date �. + Test Pit No.-1________________minutes per inch Depth-of Test Pit.................... Depth to ground water........................ VA Test Pit No 2_;._ .minutes per inch Depth of Test Pit °�t_______________ Depth to ground water........................ w ........................... Descriptionof Soil `------------- -.. ----------------•-----------------...------------------------------•-•--------------------------------------- UW ........................... .......................................__.____.__.__________.___________________-_--_____-_ ___. __ y ______________________________________ Nature of Repairs or Alterations—Answer when applicable.____________________ __.._ .__.:__________._..._.......__. -----------------------•----•-••--------------•-----------------------------='---•-------•--•----------------•---------------------------------------................................................... Agreement: The undersigned agrees to install the afbredescribed Individual Sewage Disposal System in accordance with the provisions of Article,XI, .the State Sanitary ode The undersigned further agrees not to place the system in operation until a Certificate of TCompliance has been issued,by th boa of lth. Signed -- .................................................. ----- ------------------ Date Application Approved By •-• -=-/�-h--•----........... � ..... -------- --CC+K--�---- - ar.Date. . Application Disapproved for a following redsons:----•------------=------------------ -------------------------••--------------•-•---------------...--------_.... ..............•----•-•-----•-- r -- ------------------------------------------------------------------------------------------------- Date Permit No.---- ---•-_..: ....:. Issued-•------------ . , .. -�--�---•. ........................................................ Date r s> i .- t ✓ " THE COMMONWEALTH OF MASSACHUSETTS BOARD OF ALTH .......... ..............................O F...............:::......_...................._....................................... r Wr 'r f f�nrtrla�re TH T RTIFY hat e ndivid wage Disposal System constructed ( � ) or Repaired ( ) by . ..... -•--- - ` ..........................................•--.........--•---...•-- = Inst er at_ w -----••- ------- ------ --................. -- ----_--- ---1----•-----•-----------•-------------------._...._•-----••._...__.. has been installed in' accordance with the provisions'of Article XI f The State Sanitary Coe as ' escri ed i e application for Disposal Works Construction Permit No.... __._ ` L.. `- ' `•-••---------- dated_`-- ,e .:__ _.- TW� ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CONSTRUED AS A RANT THAT THE SYSTEM TL F IdCTIO SATISFACTORY. DATE < .. ::... Inspector. l THE COMMONWEALTH.OF MASSACHUSETTS c BOARD, ;O.F HEALTH 3 ...............l1 P..:........0F........��±+�:.(.�5._�� ���.:` r No......................... FEE.... ...... - omit Permission.is hereby granted.........,, `C_ _ ° lt_ __.._.___ ........................................................... to Construct (A ) or Repair ( ) an Individual Shwa e Disposal System at No...... d✓,f,tk, .,e�_ C -Lam! ZaAr::%:.. _ _ ..: . . :..__ - -•---------------- ---- ts� Street w /i+y ! p as shotivn on:.the.applicatiori for Dispoal Works Construci©n Permlk?NQ-_- - _. ..... Dated.__.. _.._:!___K.._.___..._ �t...... Board of Health - ........................4 r,� .. ' DATE_.. . 1 '.�.- FORM 1255 Hc40& WARR'EN"INC., PUBLtSHVERS ., e