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HomeMy WebLinkAbout1097 MAIN STREET (COTUIT) - Health FI�097 MAIN STREET, COTUIT y -- - A= 034 010 -. - -- -- - �F Crocker, Sharon From: McKean, Thomas on behalf of Health "--`_ Sent: Friday,January 17, 2020 3:04 PM To: Crocker, Sharon Subject: FW: 1097 Main St. Cotuit Attachments: ANF 1097 Main St.pdf ,,Please put into'the residenfiaifile. From: AirSafe Inc [mailto:airsafeinc@airsafeinc.com] Sent: Friday, January 17, 2020 1:43 PM To: Health Subject: 1097 Main St. Cotuit To Whom It May Concern, Attached for your records is the asbestos notification form for upcoming asbestos abatement. Please let me know if you have any questions. Thankyou Terry Walsh Office Manager Air Safe Inc 978-339-5361 CAUTION This email originated from outside'of'the Town of Barnstablel"Do nofclick`lmks, open, attachments or reply, unless you recognize the sender's email address and know the,content is safe!' i L Massachusetts Department of Environmental Protection 100322638 BWP AQ 04 (ANF-001) Asbestos Project# Asbestos Notification Form C! Project Revision Project Cancellation A. Asbestos Abatement Description 1.Facility Location: T �— Y BETSY MELLORS � 1097 MAIN STt __._ . Instructions 1.All a.Name of Facility b.Street Address sections of this form BARNSTABLE must be completed in MA 02635 7814134288 order to comply with c.City/Town d.State e.Zip Code f.Telephone MassDEP notification BETSY MELLORS OWNER requirements of 310 CMR 7.15 and g.Facility Contact Person Name In.Facility Contact Person Title Department of Labor Worksite Location: EXTERIOR WALLS 2ND FLOOR LEVEL Standards(DLS) notification i.Building Name,Wing,Floor,Room,etc: requirements of453 2. IS the facility occupied? rla.Yes —rib.No CMR 6.12 3. Is this a fee exempt notification (city,town, district, municipal housing authority, state facility, or owner-occupied residential property of four units or less)? r a.Yes r7j b.No MassDEP Use Only 4.Blanket Permit Project Approval,if applicable: Date Received Approval ID# 5.Non-Traditional Asbestos Abatement Work Practice Approval, if applicable: Approval ID# 6.Asbestos Contractor: AIR SAFE INC 22 WILLOW STREET a.Name b.Address CHELSEA MA 02150 9783395361- c.City/Town d.State e.Zip Code f.Telephone A0000464 h.Contract Type: r'.1.Written ❑2.Verbal g.DLS License# 7. JAIME E AMAYA AS060847 a.Name of Contractor's On-Site Supervisor/Foreman b.DLS Certification# 8 KEVIN CLIFFORD AM000092 a.Name of Project Monitor b.DLS Certification# 9 FLI ENVIRONMENTAL INC AA000144 a.Name of Asbestos Analytical Lab b.DLS Certification# 10.' 1/30/2020 1/30/2020 a.Project Start Date(MM/DD/YYYY) b.End Date(MM/DD/YYYY) 7AM-5PM NA c.Work Hours-Monday Through Friday d.Work Hours-.Saturday&Sunday 11.What type of project is this? r a.Demolition r b.Renovation[; c.Repair ❑ d.Other-Please Specify: Revised: 11/13/2013 Page 1 of 4 Massachusetts Department of Environmental Protection-001) 100322638 BWP AQ 04 (ANF Asbestos Project# ` !` Asbestos Notification Form r._! Project Revision r` .Project Cancellation A.Asbestos Abatement Description: (cont.) 12.Abatement procedures(check all that apply): I-i a.Glove Bag C! b.Encapsulation r! c.Enclosure ri d.Disposal Only [j e.Cleanup r f.Full Containment r g.Other-Please Specify: EXTERIOR WORK 13.Job is being conducted: ri a.Indoors r b. Outdoors 14 a.Total amount of each type of asbestos Containing materials(ACM)to be removed,enclosed,or encapsulated: 300 1.Linear Feet(Lin.Ft.) 2.Square Feet(Sq.Ft.) b.Boiler,Breaching,Duct, c.Transite Pipe Tank Surface Coatings 1.Lin.Ft. 2.Sq.Ft. 1.Lin.Ft. 2.Sq.Ft. d.Pipe Insulation e.Transite Shingles 1.Lin.Ft. 2.Sq.Ft. 1.Lin.Ft. 2.Sq.Ft. f. Spray-On Fireproofing g.Transite Panels 1.Lin.Ft. 2.Sq.Ft. 1.Lin.Ft. 2.Sq.Ft. h.Cloths,Woven Fabrics i.Other-Please Specify: 1.Lin.Ft. 2.Sq.Ft. j.Insulating Cement vERmicuLrrE 300 1.Lin.Ft. 2.Sq.Ft. 1.Lin.Ft. 2.Sq.Ft. 15.Describe the decontamination system(s)to be used: NA 16.Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2) (g): 6 MIL POLY 17.For Emergency Asbestos Operations,the MassDEP and DLS officials who evaluated the emergency: a.Name of MassDEP Official b.Title of MassDEP Official c.Date of Authorization(MM/DD/YYYY) d.Waiver# e.Name of DLS Official f.Title of DLS Official g.Date of Authorization(MM/DD/YYYY) h.Waiver# 18.Do prevailing wage rates as per M.G.L.c. 149, §26,27 or 27A—F apply to this r' a.Yes rl b.No project? Revised: 11/13/2013 Page 2 of 4 Massachusetts Department of Environmental Protection j00322638 L71BWP AQ 04 (ANF-001) r Asbestos Project# Asbestos Notification.Form r Project Revision r1 Project Cancellation B. Facility Description 1.Current or prior use of facility: RESIDENTIAL 2.Is the facility owner-occupied residential with 4 units or less? rJ a.Yes r b.No 3 BETSY MELLORS 1097 MAIN ST a.Facility Owner Name b.Address COTUIT MA 02635 7814134288 c.City/Town d.State e.Zip Code f.Telephone BETSY MELLORS 1097 MAIN ST 4. a.Name of Facility Owner's On-Site Manager b.Address COTUIT MA 02635 7814134288 c.City/Town d.State e.Zip Code f.Telephone 5'NA NA a.Name of General Contractor b.Address NA MA 11111 1111111111 c.City/Town d.State e.Zip Code f.Telephone NA g.Contractor's Worker's Compensation Insurer NA 12/31/2020 h.Policy# i.Expiration Date(MM/DD/YYYY) 6.What is the size of this facility? 1525 2 a.Square Feet b.#of Floors Note:Temporary storage of Asbestos C. Asbestos Transportation & Disposal containing waste 1.Transporter of asbestos-containing waste material from site of generation: material is only allowed at the place r a.Directly to Landfill or r b.To Temporary Storage Location/Transfer Station of business of a DLS licensed Asbestos contractor or a transfer AIR SAFE INC 22 WILLOW ST station that is c.Name of Transporter d.Address permitted by MassDEP and CHELSEA MA 02150 9783395361 operated in e.City/Town f.State g.Zip Code. h.Telephone compliance with Solid Waste Regulations 310 CMR 19.000 2.If a temporary storage location/transfer station is used,list name of transporter of asbestos containing waste material from temporary storage location/transfer station to final disposal site: SERVICE TRANS GROUP 301 OXFORD VALLEY RD SUITE 803B a.Name of Transporter b.Address YARDLEY PA 19067 2673999411 c.City/town d.State e.Zip Code f.Telephone Revised: 11/13/2013 Page 3 of 4 Massachusetts Department of Environmental Protection 100322638 BWP AQ 04 (ANF-001) Asbestos Project# Asbestos Notification Form ri Project Revision r' Project Cancellation C.Asbestos Transportation& Disposal: (cont.) 3.Name and address of temporary storage location/transfer station for the asbestos containing waste material: AIR SAFE INC 22 WILLOW ST a.Temporary Storage Location Name b.Address CHELSEA MA 02150 9783395361 C.City/Town d.State e.Zip Code f.Telephone 4.Name and location of final disposal site(asbestos landfill): MINERVA LANDFILL MINERVA ENTERPRISES,INC a.Final Disposal Site Name b.Final Disposal Site Owner Name 8995 MINERVA DRIVE c.Address WAYNESBURG OH 44688 3308663435 d.City/Town e.State f.Zip Code g.Telephone Note:Contractor must sign this form for DLS notification purposes D. Certification DFW DFW "I certify that I have personally 1.Name 2.Authorized Signature examined the foregoing and am PRESIDENT 1/17/2020 familiar with the information contained in this document and 3.Position/Title 4.Date(MM/DD/YYYY) all attachments and that, based 9783395361 AIR SAFE INC on my inquiry of those 5.Telephone 6.Representing individuals immediately 22 WILLOW ST CHELSEA responsible for obtaining the 7.Address 8.Cityrrown information, I believe that the MA 02150 information is true,accurate,and complete. I am aware that there 9•State 10.Zip Code are significant penalties for submitting false information, including possible fines and imprisonment.The undersigned hereby states that I have read the Commonwealth of Massachusetts regulations governing asbestos abatement (453 CMR 6.00 promulgated by the Department of Labor Standards and 310 CMR 7.15 promulgated by the Department of Environmental Protection), and that I am aware that this permit application or notification shall not be deemed valid unless payment of the applicable fee is made." Revised: 11/13/2013 Page 4 of 4 i DATE: .311,219,495 PROPERTY . ADDRESS: 097 ill air, .02635 1�g� On the abovedate, J �,,, da e, I inspected the septic system at the above addre-sg> '" This system consists of the :following: 1 •, -:1400.0 -g-f2Qi..on. ;tank.. g. 5 .2. 1-D i.6.ti_if ut'Zon. .9,)x„ 3. '14 00.E ga-eX on. 2each.i.a g 12i1 ,aaclu:d .i.n .6tone. Based on my Ins ection, I certify the following conditions: 1,1vn ae._pt 703.—C•ode. J :2. ►Zh, Pa ,wolt jotr.g att4!-rarz ai. the /22.e.3eai .t.:m.e.. �, • , SIGNATUR•'7,: Name:-J. P Macomber Jr... Company:_J.P_Macomber & Son- 'Inc . , Add.ress:__B-._66-------A-= -- CenteirvilheLMass ' -0.2632 ` Phone:---548.,:Z7-5,.3338------ - f THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY 32 1W ,IOSEPN P. MACOMBER & SON,. INC. Tanks -Leaahifeids Pumped I lnsislled Tawn Sewer Connections P.O. Box 66' Centerville, MA 02632-0066 773-3338 775-6412 SEWAGE DISPOSAL SYSTEM address Of Property, 1097 •Ma.i.;z Si/-ePI C0.tt1ii,1Ia.3b. Owner' s name Day.id F-iAh Date of Inspection 8130/95 • • PART A CN L'CKLIBT 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 normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. _—ZAs 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 site was inspected for signs of breakout., All system components, occluding the SAS, 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 SAS on the site has been determined based on existing information or approximated by non-intrusive methods. _-Z— The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance -.of SSDS. . LI b. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION FLOW CONDITIONS.' If residential number of bedrooms number of current residents _ DL garbage grinder, yes or no laundry connected to system, yes or no ' seasonal use, yes or no If nonresidential , calculated -flow: Water meter readings,;r if available: lqA'3 4lj Z7/5 ' t •�'3'G'�� Last date of occupancy GENERAL INFORMATION Pumping records and foUrce of information.- — ' _ System pumped as part of inspection, yes or no if yes, volume pumped Reason for pumping: , Type of system 1/ Septic tank/distribution box/soil -absorption system • Single cesspool Overflow cesspool , Privy, din Shared system (yes or no) (if yes, attach previous inspection records, if any) _ Other (explain) Approximate age of .all •�components. Date installed, if known. Source of information:. ,- .. .. --.. ....._...... ....... ...__... .... _._._.. _....- - �7' Sewage odors detected when arriving at the site, yes or no J • �1 9 . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SEPTIC TANK:—"9/Z-4XV nwoe (locate on site plan) depth below grade: material of construction:. oncrete metal FRP other(explain) dimensions: r sludge depth . " distance from top of sludge to bottom of outlet tee or baffle 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, structural integrity, evidence of leakage, recommendations for repairs, etc. ) 64 c ` DISTRIBUTION BOX:__ __ (locate on site plan) 11C� 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, recommendation for repairs, etc.) PUMP CHAMBER:] ON (locate on site plan) _1 pumps in working .order, yes or no Comments: (note condition of pump chamber, condition of pumps and appurtenances, • recommendations for maintenance or repairs,etc. ) 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued 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. e r leaching pits and number leaching chambers and number leaching galleries and -number leaching trenches, number, length leaching fields, number:, dimensions overflow cesspool, number Comments: (note condition of soil , signs of hydraulic failure, level of ponding, con itio of vegetation,' recommendations for maintenance or repairs,etc. ) y3 CESSPOOLS (locate on site plan) : t number and configuration.' depth-top of liquid to, inlet invert 1I441—jr depth of solids layer depth of scum layer Ada"- . 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, recommendations for 'maintenance or repairs,etc.) PRIVY: AVXj,� (locate on site plan) materials of construction dimensions depth of solids Comments: (note condition of soil,'' signs of• hydraulic failure, level ofponding, condition of vegetation,-. recommendations for maintenance or repairs etc. ) . 1VOAVE SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.,PORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE L=SPOSAL SYSTEM:. include ties to at least two permanent references landmarks or benchmarks locate all wells within 100 t• • /Pli vw _ 1 f � r ' DEPTH TO GROUNDWATER , depth to groundwater methoof d ermnation or approximation: t ,�,� 12 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C FAILURE CRITERIA Indicate yes, no, or not determined (Y, N, or ND) . of determination in all instances. If "not determined" �e explain scribe b whys not) _.dlL�• Backup of sewage into faeility7 _A10_ Discharge or ponding, of effluent to the surface. of the ground or • surface waters? _dt�2 static liquid level 'in the distribution box above outlet invert? 4.," Ar- Liquid depth in se�ss�oe•1 ' <6" below invert or available volume< 1/2 da flow? y -A& Required pumping 4 times or more in the last year? number of times pumped - n-- e �. Septic tank is metal?, cracked? structurally unsound? substantial ' infiltration? substantial exfiltration? tank failure imminent? 1 Is any portion of the SAS, cesspool or privy: below the high groundwater elevation? -.442 within 50 feet of a surface water? water 100 feet of a surface water supply or tributary to a s supply, urface _d112 within a Zone I of a-public well? —AD- .with-in 50 feet of a bordering vegetated wetland or salt marsh- (cesspools and .privies ,only, riot the SAS) ? -4/0,- within 50 feet of a private water supply well? less than 100 feet but greater than 50 feet from a .rivate supply well with no acceptable water quality analysis? If the wellfor co en analyzed to be,. acceptable, attach copy of'well hater anal! for coliform bacteria, . volatile organic compounds, ammonia l+and nitrate nitrogen. nitrogen-- TOWN OF L3I:z.zn,3Yafl­er, BOARD OF HEALTH SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D .- CERTIFICATION -TYPE OR PRINT CLEARLY- PROPERTY INSPECTED STREET ADDRESS 1097 Ma-i a St a as IL C o I lj,.i 1 N(y,6'?5 ASSESSORS MAP, BLOCK AND PARCEL 0 OWNER' s NAME -C. TlAh a-- PART D - CERTIFICATION NAME OF INSPECTOR, COMPANY NAME Son, Inc. COMPANY ADDRESS /30466 Street Town or City State tip COMPANY TELEPHONE 508 77-5 3338 FAX 508--) 790 75.78 CERTIFICATION STATEMENT I certify that I hav e personally inspected the sewage disposil system at this address and that the information reported is true , accurate, and complete as of the time of inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one: XXXXASystem PASSED The inspection which I have conducted has not found any information which indicates that. the system fails to, adequately protect public health or the environment nment as defined in 310 CMR 15 - 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. System FAILED The inspection which. . I have conducted has found that the system fails to protect the public health and the environment in accordance with Title 5 , 310 CHR 15 . 303 , and as specifically noted on PART C FAILURE CRITERIA of this inspection form. Inspector Signature Date 3.130195 One copy of this certification must be provided to the OWNER, the BUYER ( where applicable ) and the BOARD OF HEALTH. If the inspection FAILED, thv owner or"'operator shall upgrade ' the system within one year of the date of the inspection, unless allowed or required otherwise as provided in ,310 CHR 15 . 305 . partd.doc, f C=1 innonwecrr ct massccrsers Execorve Gtficn cr Envircrr enrc; r."0: Department of Environmental Protection ' Water Pollution Control Tecnnlccl Assocnce and Training Sections WUtlam F.Weid c oar~ Trudy Cox* Swewy.EOEA Thom" 8.Powers • 06/12/95 ATTN: Joseph P. Macomber, Jr. Joseph Macomber and Son ; PO Box 66 Centerville, MA 0263=- Dear Joseph P. Macomber, Jr. , I am pleased to inform you that you have attended training, met the experience qualifications,� and have passed the Title 5 System Inspector exam, pursuant to 310 CMR 15. 340. The passing grade for the exam was 39/52 or 75%. This is an official notification that you are a Certified Department of Environmental Protection System Inspector pursuant to 310 CMR 15.340. You will receive a System Inspector certificate at a later date. If you have any futher questions, please write to me at the following address: 1Cimball Simpson D.E.P. Training Center 50 Route 20 Millbury, MA 01527 Thank you very much for your time and consideration in this matter. Sincerely, Kimball T. Simpson, DEP Training C,:;:.-:.er Director (2405) Route :°o 9 Millbury, MA c e FAX 508-755.9259 • r--e none 508-756.7:41 TOWN OF BARNSTABLE LOCATION SEWAGE VILLAGE ro;ty"174 ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO.,�f1���'��w SEPTIC TANK CAPACITYC LEACHING FACILITY:(type) NO. OF BEDROOMS PRIV TE WELL OR PU C�WA BUILDER OR OWNER4E(S DATE PERMIT ISSUED: DATE COUPLIANCE ISSUED: • VARIANCE GRANTED: Yes No .► � �, 1 �� � �i �,. � ,� 3 '`�, � �.. �� � 577 TOWN OF BARNSTABLE LOCATION SEWAGE # VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: �USATE COMPLIANCE ISSUED- I� THE COMMONWEALTH OF MASSACHUSETTS BOAR OF HEAL c. �-4-- il Appliratiun for Diupuual or �C�,un�#rnr#iun rrmi# Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at: ,• .., ...................... . .......................� :f-- .... ..: v.. 1. 1... .......----.......................................... ocarywi-Address or Lot No. . ------�. 2.................. -----------••--••-------------- ---.... ......._..------------..-..........----------_ -- ------ C - -ss Installer Address UType of Building Size Lot............................Sq. feet Dwelling_ No. of Bedrooms.........__.................................Expansion Attie ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons............... _........ Showers ( ) — Cafeteria ( ) Otherfixtures ---------------------------------------------•------------------•----•--- --------------------------•-----------._.... ------- ------------- w Design Flow............................................gallons per person per day. Total aily 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 ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................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..........:............. a •-•-•••---•---------•--••••••--••----•------------••---•-------------------------------•-•--.......------------------------------.._.._•------...........--- 0 Description of Soil................................................................................---------------------------------•-•-------------------•-----------------•----------•-- x U --•--•------------------------•-•------•-•----------•-•----•----••-----------••-•-----..........-------------------------------•---•-------•-._...--•-------•--••-•-••----------------=----•--.._...___ -------------------------------------------------------------------------------- •--••-••-------•---- Z. Nature of Repairs or Alt ration —A sw wh n a hca to � _ -----• -- P' U P P / f •• , .� S Agreement: 67 The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersi ned further agrees not to place the system in operation until a Certificate of Compliance has bee�id he r of health. Signed j . � -•-•-- --- -------------A . ----- Date Application Approved By----•---• J .._..0..(,�e"" J ----•---�f� Date Application Disapproved for the following reasons---------------------------------------------------------------------------------•--•------..._..----......------ --------------------•-•-•----•-•----------•-•---••---•------------••-•-••-------------••-•--------•--------•-------------------•---•---------•----•--•--------•---•••-••--------------................ Dat& PermitNo..... ...................... Issued_....................................................... Date r Fps .....©....... THE COMMONWEALTH OF MASSACHUSETTS BOARR OF HEAL I _.70..W.e!...........O F..........�......h...... .Q ..._....C........................... Appliratilan for Disposal Works Tonstriirtiun Prrmit Application is hereby made for a Permit to Construct ( ) or Repair ( aan Individual Sewage Disposal System at: �j .�.1.e... .... _._ /.._... :. ... ;, ..--..... ,�. ! !.... .................................................. J,oc -Addres or Lot No. ..�/��T.(.�...:!.:...........T_...�,��A................... ---,........................................._...._..............__._............................. w ...�..., �t ... R /.5............................. _ c-�? ss....... -------... ----..... Installer Address UType of Building Size Lot............................Sq. feet Dwelling. No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) d Other fixtures ---------------------------------------•--•----•-••_.... WDesign Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet....................•Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date.................................... Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water-._-_-__________---_.__. fT4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------_................. P4Description of Soil-•--•--r----------------------------------••---._•---.•----....---•----...------._..........-------•-•-------•-•---------•--•-----------------....__.....-----••---- ....•..............•---...------------------------------------------------------------------------......-------•--- x U •--•-•---------••-------•-•---••---•--•------••-•-•-----•-----•---------••.........-•---•-------------•-•-•......-•----•-----------••----.............................................................. x --------------------------------------•••---------•-----•----------•-------. ................................. Nature of Repairs or Al ration A sw wh a licable__... ____......_ .' ..U P Pl�� .. Agreement: The undersigned agrees to install the aforedes,cribed Individual Sewage Disposal System in accordance with the provisions of TITLLE 5 of the State Sanitary Code—The undersi ned further agrees not to place the system in operation until a Certificate of Compliance has been i,5eued he br of health. Signed--- --------------•----- ............................. . Date Application Approved BY � "'�,------ fir` "" "�.- ke�! t J 0 J , Date Application Disapproved for the following reasons---------- ----------••--•-------•----------------------•------------------------------------------•--••---...... •..............•--•--•-••....-•-•--•--••....---•---•-••.........--••-....-----•••.....-------••------•••••-•----•-••••-••••-•---•---------------•----------------•-•--------------------•------...-•--- Date Permit No....-_� ,1. -,.s- ................... . Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...............OF.....fY4i' .. . t...... ............................... (9rdifirab of Toutplianrr THIS I RT FY T fth�e ndi 'dual Sewage Disposal System constructed ( ) or Repaired ,�•}^""°' by /9.,4EE nstaller ...t has been installed in accordance with the provisions of Th" 7� 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......�t 6.)........ dated________________________________________________ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE..............:..... :': Inspectpr. THE COMMONWEALTH OF MASSACHUSETTS BOA OF HEALTH .. .............OF 1��W ).e...............................No..... FE; - t............. Disposal 0 • inn inn rr it Permission is herebygranted..... . ..(0f- .._�f"�___ .1....g `d� to Construct ( ) or Repair an Individ al SeH7age Di System 1 atNo........ ...... .................. t Street ' as shown on the application for Disposal Works Construction Permit No. ...`............���. Dated.......................................... ............................... .................................................... DATE-----... .-d-"3--�-��.�....................-•--•----•---------•-• Board of Health �a FORM 1255 HOBBS & WARREN. INC., PUBLISHERS