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HomeMy WebLinkAbout0248 MARINER CIRCLE - Health 248 MARINER CIRCLE, COTUIT A = 024 138 ---- -- -- - - - -- -- -- - ---- TOWN OF BARNSTABLE 60 c` L&CATION irel� SEWAGE # 00—329 -V'III AGE ASSESSOR'S MAP & LOT o INSTALLER'S NAME&PHONE NO. JOinPX )9", o� SEPTIC TANK CAPACITY /000 LEACHING FACILITY: (type) �°,SoG Cal D.�� ��`l (size) 2 5X /-I NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE:/ ,2 —66 COMPLIANCE DATE: G o0 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by v . s .i No. w v Z Fee ✓ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Rpplication for �Dioogaf *patent Construction Permit Application for a Permit to Construct(4_)-gepair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. /� l/LJ64/"!h `' C/r'G1/_ Owner's Name,Address and Tel.No. Assessor's Map/Parcel CoTrJ�T ✓E`t�I FFr /�or3 I� f4 Installer's Name,Address,and Tel.No. f`�— ��y Designer's Name,Address and Tel.No. ✓ps C,4117 a---- i�3•torr0�/ ✓(js rC�'sS e 9,9r,S of /4 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank �C'147i� Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) , � SrOG!-� �l��y�ia✓ 2 " f rl���rrsh� Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health. Signed Date Application Approved by �' Date Z `OU Application Disapproved for the following reasons I Permit No. — �� �s. �— Date Issued — —�—— —— No. - � •ak, .c• - Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Zlpprtratton for Mtgpogal 6pgtem Cottgtrurtton 3dermit Application for a Permit to Construct( pair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. /2.y3 IA114r 14.e e C/rC-& Owner's Name,,Address and Tel.No.,, Assessor's Map/Parcel Go7"vl 1' ✓��Is9�/'ir �ar3/� 02 Y - Inst/aller's Na/me,Address,and Tel.No. Lf 71-0:�r4 f' Designer's Name,Address and Tel.No. � ✓D,S Z'r©�l !/-C ��f?r'rt7s J�j s yr��j uG �/4!"✓t�J� / , Av, / Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank X /4Uz? Type of'S:'A:S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Zde Va 4s 1 Y Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system -in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- Cate of Compliance has been issued by this Board of Health. Signed Date Application Approved by �' ,3 Date G- Application Disapproved for the following reasons r Permit No. Date Issued ------------------t / --1' ------------4-- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certtftrate of Comphattre THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( 4-)-Repaired( )Upgraded( ) Abandoned( )by _ Ja.T�,.�G. at (!�'iarvi7" has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. Zr"-3 2 ej dated G' Z- Z-0-al-d Installer X�/, Designer os Z .5 The issuance of this permitAall° of b construed as a guarantee that the system will-function as d4s 9ne /3 Ij j Date d + Inspector /r�, vC ., tl �� �✓jJ No. � .'. 3 � t --------------------------Fee �— THE COMMONWEALTH OF MASSACHUSETTS D 2 r 1 PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Mtgpogar *pgtem Congtrurtton Verrait Permission is hereby granted to Construct(pair( )Upgrade( )Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this p rmit. - Date: z Z0 Approved by 1/61" NOTICE: 'This Form Is To Be Used For the Repair Of Failed ,Septic Systems Only. CERTMCATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) , hereby certify that the application for disposal works construction permit signed by me dated ( - 2- oo concerning the property located at 241E lo (-.2-1 < �Tyi � meets all of the following criteria: The failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. ,OP"--The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. C/There are no wetlands within 100 feet of the proposed septic system G-�Th ere are no private wells within 150 feet of the proposed septic system There is no increase in flow and/or change in use proposed C-7here are no variances requested or needed �^ e bottom of the proposed leaching facility will not be located less than five feet above the v maximum adjizted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] • If the S.A.S. u�011 be located with 250 feet of any vegetated wetlands, the bottom of the proposed leaching faca.,y will nZ be located less than fourteen(14) feet above the macimum adjusted groundwater table elevation, Pleax complete the following; A) Top or.'Ground Surface Elevation(using GIS information) E) G.W, Elevation . -3 + !-7 Z _ the MAX G.W. Adjustment , _ 9 DER: ICE B 3 BETWEEN A and B SIGNED � 3 (Sketch proposed'plan of DATE: q:!kalih folder;cart SYSTI n on back). — 0 �9 - q n L � 0 o v J n S a n 0 i s l l BOUSFIELD SANITARY• SERVICE Q 451, ROUTE 6A N.U. HUX 438 b� EAST SANDWICH, MASSACHUSETrS 02537 �1 ri .' 'W*6 o® 888.2010 S Ep 199 M1 2 .1 ' 7 2 c SUBSURFAM,SEWAGE; jI8P,0SXL BYOTEfi�INB{PECTION , a Address of property q4'9 /�I/ /P/NCR C/�C'1��: Cd j U/% owner ' s name Date of Inspection ` . ;,.,:PART, A 6BECKLIST check if the following have been done:.; { of the owner, occupant; and Board of Pumping information was requested Health. None of the system ;components .hay.e tbeen,pumped 1for at 1e60tt a peeks ` " {f Normal`.' 1"ow rates"during and, the„ system has keen 'receiving _ �,, Large volume -7 f waaterr+ha�i"bt-'been- introduced into the _periods _L u system recently or as party of "this'`°inspection. r As built plans have been obtained• and examined:, Note if they are nat' x•+.. .- w darwn 4rrx?,r'',•taa..s, 'Sr+ e'Yi(Y & 1 J;w /w s ti t.(! available with N%A. `r+xa,• F.Y it or dwelling was , -signs of sewage back t�xl'h e ..f a w * r ✓ The site was inspected for -Signs of breakout. y,t� i *. .t.=J.. Ei ..lt{r"r '+rb.i ., , • ; • «. �.v +i` ,9 L' r c a • '•°On e Have 'tieeri. located All system components, '"excluding the SAS, , •'b�c, ,. ^ ,z F site. .. - k ., .k,fie'§e�±•ra"�"�'i�';�' "+'! '# ':x t,� ,. ✓� The sep,ti, tank ;§aa,��;off :,;.wrere +arc®vexed. '.opened, and the` interior of. the septic tank was inspected for,condi'tio of baffles or..•teet; material of construction,Aimensions, aeptt of :liquid,## depth of w a t w. sW.wpde'tix�.3,.cV'.�r• .k• �i�#�'��,,.%�� �i .F 1 Z ti''a .. (k .sludge�_"`ddj tl '"61f scum:" na(-rrMr +;, ,..s ; s, +g l` .a �iy`�.t+ r v }yy�.i?xk�fi Jti ,.% d 7 -yq,.•; �„� �;. 1.1J.•;r'.,M•„�k "1.. �.•b'�iF T-3 p,`s',3 �•F i 4. ..' M on of The size' loca ti ,,the on °8A3 . t1e, site has `beendeternnec based and on existing information';`or�approx�irn tedi by >rion-ititr s iv } u e- niettt�ds * . .,o-,..,i;;.;zun+r.V•w.wTi.,wvwv-.:- .a swes.•.ti4 ...ri«.,,ow •^t.' '...=..u • .e �'t �'IKf� 'v' ,k+RN ra+d.^•' y 'f i ".�.:=3�Yvie' "•+,.ti»..+1:.:^ 'L t t i"^•}�k fie t Artie facility owriek`'(aridPtoccupan ibtr if*different from ,owrier) were +' wpr;ovided with, information'�on the-.. r.p er maintenance of SSDS F #,.Tg „'Y rxY>:'§t.%k::k -A+ '•!' �'S4"?' ..a. °" 1. ` .j _' + F'k�yrw8a'tti ':;:4,r #:' y II SUBSURFACE SEWAGE DISPOSAL SYSTEH INSPECTION FORH PART B SYSTEM INFORMATION k ,,e, tom, } '��� :•„ r I 'fit � +,s FLOW CONDITIONS lf-'.residential number of' bedrooms . a number of current .residents " p garbage.,grinder, ;�yes 'or no ). :laundr connected to "'s stein t.. ', 'Y Y yes or' nv .. _/iL0 seasonal use, yes or,.no , If nonresidential , calculatedrAnow:"'y5 V / e W a.t a r mete r readiaa,�s,.--if 'avai`lable:`• Last date of `occu anc`; P Y . r r > a GENERAL INFORMATIOPJ PU1nP;ng,,,records z ".,f�, y and source i ofnformation: ` t f � " y yC 1*. ? '• ,'a'' is ',t . .�.�, . Systems pumped, abspaxt of: inspection, , yes or no if yes; volume" pumped1t ip , . fi� •, : R , w . Reason for pumping: , o:.¢y{1 f Nf,f7 .a �,.. y, f.� .#I ,e � - °d � 1. 4 r! 'i'Type _ a of system `car �- �.�:,_= f,i, u�r �,. ;<� -•,j � {;. ;, Septic tank/distribution box/poil absorption system V Single''cesspool`5x , overflow .cesspvvl . r Privy; ,.•, , ti. `-#"Shared s stiem es or no z "x Y ,f Y x ) (ifs, yes, attach-� previ•ous Ri»spec��on _:° r�•: jrecords, , R t Other t(explain f r " < .� .. �.�t . r 711 : -,e ._, t is •x- ,., :, Pproximate age5of all components. Date installed, if known. 'Source of xi iformation•, .'Q w r 111I1f `"•"'�'`s +rX.' f`,t '.�k'�'..'ia� .G/'�IG.r.$, *�,,.,�`a aj -'+� i�-trt ft M•+ " �'�t'� 4� x':.t xi"YS.) Sewage odors detected,."when arriving at° the sine, yes or no 9 *SUBSURFACE ,SEWAGE DISPOSAL SYSTEM,•`INSBECTION FORM PART B � � BYSTEMv°�INFORMATION 'coatinued SEPTIC TANK:_ (locate• on situ=plan) depth below grade:_ /,_ \ material of construction:.. ✓ concretes. metal_,. - ..-FRP other(explain) dimensions: 'ry +sludge depth '-distance,• from*top.,of .sludge to bottom-,of�=outletvtee`,�or' baffle scum _thickness. - -T distanc fror._top_vof,-scum, to. topttof,,nutlet'"tee -or''baffle •' ` distance_.,from_bottom-of., scum ;to� botto1n0'of outlet, "tee- 'or baffle ' Comments: (recommendation for pumping, condition of inlet and outlet tees' or baffles, 'depthvof- liquid" level° 'in` rel'ationA6* outlets invert;" structural integrity, evidence of, leakage;-9 recommendafioris for' repairs', etc.,) e•� +•? f M F'e DISTRIBUTION.. BOX: ✓ ..(locate on_site,.plan) depth�of_liquid level above outlet finvert _ ...�. Comments.,_.. , .._. _ _ .. ., - .��t;=s3 �� . :, •{ xx ��\.�t z: (note if level. and distribution is;equal£;zevid"ence'=°of solids ;carryover'; evidence of leakage , nto_or.. out of box, recommendation for Trepairs", .ietc ) ... �.e _ __.._ . yyyy.•, z t _ ,rt k w;•�. `s' yr «r *,e—j:I"F Sst'a J t.3' N PUMP-CHAMBER: (locate on site plan) pumps in working order, yes or no Comments: ""'(note •condition ofApump chamber, ' condition of pumps and 'appurteriances = ' recommendations- for maintenance' Or repairs,etc. ) , 'Y • �fr,r•3 t+. t` <c �', :}"s 1.� ire .0 ILr;{Y yy�. LL +YYyy. p } t.A\ 7::D MI 3i - -r. $ •aww •r��§�_ S'.r i''<�`"�' t' �E4yi. ipi•�: '' `' !,,., 4 � r , a � ,, B.UBSURFACD*SEWAGEJDI,SPOSAL!SYSTEM 'INSPECTION FORM R ;( PART B ,n,SYSTEW INFOR?UTION continued SOIL ABSORPTION SYSTEM (SAS) : 1/ t (locate on site plan, if ,possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be, present, explain: a N M1.. 4 r-s...v.y: i.r..•.3Y u`� M-......r. ... ,: .. .. R I'.. T e" YP leaching pits and number — Le,.C-,z r chambers -and umber, leaching, 'and n ,��;�-� � _. �< � • ,t � � i leaching galleries and number I each ing,Atrenches,,,.number,;:=~length leachin fields , ., g - ,number�;.�.dimensions overflow cesspool , number Comments:, (note condition: of soi°l ; signspof��hydr.aulic: failure,.," level of pondirig, condition of vegetation',• -recomniendations-,for,,maintenahce or repair's,+etc. CESSPOOLS R (locate' on ",site =p1an)"• } number and configuration depth-top of liquid to inlet invert depth of solids layer .k; ,, depth of scum layer '�W% dimensions of cesspool materials of construction indication of groundwater •fit°inflow;dj(cesspool ,,must„be um e,d as r .» - -. '� f �� ,,part;'ofjrinspect�ion) PAP t, RW�. �. . :tom E :n: e . Comments: . .._,n... ., . •» ....n ,.�.. ,... _�.,..,.,-,..��, ..,.w,,,.�.w _ _ ... _ �. w-• L. awy.iF1 ...iWaa.w:°.:.r.+i:-ems - (note condition of soil., signs' f hydraulic.jaildre,_.1evel 1ofN.P6nding., condition_wof vegetation, recommendations..,for,,,maintenance -br-kOpairs;etb:) Y»I!+ PRIVY: ,:= (locate on site plan) aJ71 materials of construction dimensions so depths Of� lids y y o ' _ t.; iy '.a.. iG � ." ;���.s�....7.[.�,r'��,.f;3 "A�'"f t��,'.1�.�� ,.}r�,r �..,� 5''.w �C,o- + • w� -� 5 .e j .4;:..,. Comments (n ✓.... . .— ... ..--.«. .. A.,3"R..+in +rt^^"<�wi +++W " x+a•aM .+•wel.rws.W+u..xW -,Y.rt ..{.,•.•a'+s.. ..9e�.:.w. � d'M.+.wnwr .e..wr., nT+V.,...rvy .. ote..wacondition of: soil,,i4signs of;hydraulic, failure, level_.of ponding, ' condition ofvegetation, recommendationsfor" -maintenance ..or :repairs etc: r - ' 11 SUBSURFACE,,SEWAGE. DI8aP0SAL SYSTEM INSPECTION FORM PART B -SYSTEM%,INFORMATION jcontinlued • ., .' i r {r t^r. •i f 4. y t..-{ 15.j i .�,'!,dY» �-y° y:Y� '• } � 1 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two `permanent references landmarks or benchmarks locate all .wells within 100 ' , } ;;Ff . 2; «.: _ • . a r .rt f f":' _o ,F t�.w .t, aid +5 ° {�; .' � ., .t 'T f , r `+, VeAc 32 TAW iC • Va L �1 x�j'-L ..Y ,r v ,�µ•' °.�,a f.r�'. '�C,a��f '`.4 E ... 4. _ .. { t,,.t, 0 ram`,° •., r: rl t *'toy. #. .}T sy ?4 i.'? `r ` S ' v`N'. DEPTH TO GROUNDWATER Jam/ depth to groundwater method of determination or approximation: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C Indicate yes, no, or note-determ`iried'�'(Y '"`N,°'`or ND) . Describe basis of determination in all instances. If "not determined", explain why not) /V yBackup of sewage into facility? Ai Discharge or ponding of effluent to the surface of the ground 'or surface waters? ,. Static liquid level in the distribution box above outlet invert? Liquid depth in cesspool <6" below invert or available volume< 1/2 flow? Required pumping 4 -times or more �in the last year? number of times pumpedy'•�. Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltratrion? tank failure imminent? Is any portion of the SAS, cesspool or privy: below the high groundwater elevation? within 50 feet of a surface water? within . 100 feet of a surface ,,water supply or tributary to a surface water supply? N within a Zone I of. a public well? within 50 feet ofabordering vegetated wetland or salt inarsh � �l (cesspools and privies only, not the SAS) ? within 50 feet of a . private. water. supply well? less than �iook feetSbut '4reaterv#than--50 .feet-from a private water . - ,-"- .supply-well--with•-no-.acceptable-water-qual-i,ty-analysis?, If_-,the well` -- has-been-ana1yzedM.-�to--be-acceptable;,,_attach­copy� of-we1li -water- .halys . _ o,,yfor.-coliform-•bacteria,.—volati•leorganic-,compoun ;•-a dsmmonia,'-nitrogen- and--nitrate 13 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D CERTIFICATION Name of Inspector Company Name Company Address ' a Certification. Statement I certify that I have personally inspected the sewage disposal 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 r`egar&ing upgrade, ' maintenance and repair are consistent with my training and experience in the proper function and manitenance of on-site sewage disposal systems. one: ZI have not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15. 303 . Any failure criteria not evaluated are as . stated in the FAILURE CRITERIA section of this form. I have determined that the system fails to protect public health and the environment as defined in 310 CMR 156303 . The basis for this determination is provided in the FAILURE CRITERIA section of this form. Inspector' s Signatur Date . 12 Original to system owner Copies to: Buyer (if applicable) Approving authority w ,�-,Nr- ^�"�-,. ix+ x,��"'., _, �.r,7v o-,^'-r �yy :- ,y,`.,fi,�a �,, 1t,-.,A.S- .,u�`'�-> x`"^-",�.'az-* ..� -„t a. �txi-i r ,L�.- a., u :-t�� r "k C. i' w '4�y„ ' ' - �x -'-' + +xe "3r - rya t s: !-,. - - - } i t = _ - TOWN OF BA/RNS'TABLE LOCATION 2 5'B l2gn/�e�" �/ elite EW - r S AGE # �0 329 +v `:A t. ' VILLAGE 6_07Vi7" ASSESSOR'S MAP & LOT o 2 Y- /3� Y� �x .. . , : .. , INSTALLER NAME&PHONE.NO. �OYPli /�� �!^ra� , d bP .! 1 w x , SEPTIC TANK CAPACITY /0o6 -5 _ 5 LEACHING-.FACILrrY:.(type)'_ ,- -i p :��� (siiej� . 5 i I. /11�. ,._ . I I A it NO:OF BEDROOMS 9- . . r t ER OR OWNER_ 41/7r-vlC _ BUII.D-- — PERMIT'DATE: z -6d COMPLIANCE DATE: G oo ` r;�.`_ _ Separation Distance Betweenahe: F' . . . . . Maxunum Adjusted Groundwater Table to the Bottom ofLeachingFacilty ` Feet �. - tf Pnvate Water Supply Well and Leaching Facility (If any wells east a' ` w' �,.;r .r y on site-or within 200'feet of leaching facthty),' , kw °sN3'" E f Edge of Wetland and Leaching Facility(If any wetlands exist - . a t Feet "� �� y� a�vithm 300 feet of leactun facih ) Feet r. l .! ^"'C 1 ,,Ey .F $hedw e3 .� `",�' �s'"iFj t Syu� r t, t Ha7 su, 3i J t t t i r i v u', P;t : 7 i �'�p l't., x,"'-i T A - t.s`ra c < t s t�: - t t a dw t J7�"w�t n'� t psI,f s "n i' k 1 n" t r 7 4, — „ :.^ : �i '. � F P(. :. .. A.. € _..: `.'. !Fl �,.- .. : -- ems ,tE ".. C a >+'. -1' yp .%11 4 . .. : - .... -.-. y .. {9' t!� O4.3 i - ¢�¢ x �hP ;f '3 i2 ,er x i .I t'C- q7 �S ' ` r ` t _ t 2-El, .. 11M?'tf 2L - 2� i' -y w8."'�. \ m t. ` t t t ;t h �s t `� ss ' i�r ` `'- `x s �;F t`gi}"�x t ��5'•-.12 " sc�°. ws aYR_ , r a _ } }n -..x t t i e .�.. ' L{'tYCs72,v�� R -�-s' `�-��" ° ,.q,w t .S f ti t t i F'11 '-� Y ! tF 4 '.#t" l} i.. �, t ss - • t n L . i r - -S, i r} j F tTi,tk E? - a. __ . �� t . ��ap o C".: - ' r' l y __—,-_�. ... _..-. .... _._...-._.__ ... _— — _ ___.__..___.-.__—. _ .-_--.. �� F I - ¢ - .. - - - I - - - i - '� _ -.._- .. :, '"^ -N D. '..,'t^a-4 wYam4y,s -'J�'y!"°` '@y-:` f'", , 'w,'J ,,,y^y,. '",�"i" -r�'�"i 4- a LOCATION SEWAGE PERMIT NO• VILLAGE 9 IN T , LLER'S MA E i ADORE,� S or BUILD R OR OWNER r DATE PERMIT ISSUED DATE C01APLIANCE ISSUED 3 � %� *Cry �,r 5 �Dj 131 NdQ -............. ......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 11140Y.&O wx_'o 0 --------------------**----------------------Appliration for Uhipoiial Workii Towitrurtion Prrutit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: 0Z ................. .................... ... .......... 6 ............................................'44-4w d r Lot ..... .... ... .7............... ........ Owner Address .... . . . ..... .................................. ................................ . ............................................................... aInstaller Address 9Q Vt Type of Building Size Lot.(J At.70.....Sq. feet U Dwelling—No. of Bedrooms........... ...................41 ............Expansion attic Garbage Grinder Type of Building Cafeteria Other No. of persons....... ----------------- Showers OtherfixtLuws .........................I............................................................................... Design Flow........... ................. --gallons per person ler d Total dail ACV- clay. —Y Y-10 M gow.... Ix Septic,Tank—Liquid capacity gallons Length .....:....... Width---qj ..A.. Diameter................ Depth...._..._....... Disposal Trench—No. .................... Width...P�............. Total Length.................... Total leaching area....................sq. f t. Seepage Pit No---------/--------- Diameter........?......... Depth below inlet...Y3.4.... Total leaching ar .sq. ft. Other Distribution box Dosing t* Percolation Test Results Performed by..111401&�..:Z-14101119*1............ D at e...'14. . ------------Test Pit No. I------Z— minutes per inch Depth of Test Pit.................... Depth to groun water.. 44 Test Pit No. 2................minutes per inch Depth of Test Pit.___............__.. Depth to ground water., & P4 ........... ... ... 0 Description of Soil--------------------- W ------*-------------------------------­*------------------------------------------*........"----------------------------------------------------------*------------------------------------*---------- ....................................................................................................................................................................................................... U Nature of Repairs or Alterations—Answer when applicable._............................................................................................. ....................................................................................................................................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee {�_.'ssued b ompli nce has ee ssued DiyY&bDoaV of, health.dig j I igned . ...... . ....... . .. ............................. ....... to /............. Application Approved By.................... .. .... ...... -------- 71 .................. ....... 7 Date Application Disapproved for the following reasons:.............................I............................. .................................................... ........................................................................................................................................................................................................ Permit No. Issued--- 17 //_ *_d.........Date ........................... ............. Date No...._.....f h u_ Fim............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .!r�r!r...------------------OF...... ![Us•rt!*J' cc!`'' 1. ,......._.. Apphration for Disposal Works Tontrnrtion 1hrutit Application is hereby made for a Permit to Construct ( } or Repair ( ) an Individual Sewage Disposal System at• o 11,74 WZ' .,.0 /...A`?,ct_ /r2 ..... .... / Location'Addre"s's �.... \ o Lot No. Owne�r ♦ Address -r'� ..................--------------- ------------------ Installer Address Type of Building . ;� Size Lot._- ..._: -----Sq. feet V Dwelling—No. of Bedrooms__________..................................`-.. Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ' f + ...... No. of persons........Lf_---_---------- Showers ( ) — Cafeteria ( ) Other fixtur . '�` W Design Flow...__......,'�� .................gallons per person per day. Total daily flow____....._.r .2 _gallons. WSeptic Tank—Liquid y capacit .gallons Length.Z.y!!rf.. 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_' ft. � P� .� ---- P g ..>-----•------sq• Z Other Distribution box ( /) Dosing tank ( ) J '-' Percolation Test Results Performed by..... � � - ............ Date----C� ; ------------- a Test Pit No. 1------Iw►.--minutes per inch Depth of Test Pit.................... Depth to ground water.. ±'.1� ' +C. (i, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.A..�%'W; 04 ---•-------------------........................!......... 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V Nature of Repairs or Alterations—Answer when applicable.-____•........................................................................................ ••-.......................................................•................. -•---------------•---•----.....-----------------------------------------------------------•......--•-.._..--------•--• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITlE 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. igned. r /C!' . l ff±�- -•-------•................... ....�.. l to Application Approved By....... r< �� .. -------------- ......... y E• Date Application Disapproved for the following reasons:------•--------•---------------•----•------------------•-----•------------------•---------•---••--•••-------.... ............................................................................................................................................................ ----•------•---•---•-•------------- Date PermitNo......................................................... Issued....................................................... Date }ri THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH er .......... .........................................OF . .................................... Trrtifiratr of Toutpliatta b THIS�IS TO C-ERTIFY/That the- Individual Sewage Disposal System constructed (X or Repaired y ( ) ��...� � ........................................................ at.-----------=--------•-.....-.................................... (lam has been installed in,accordance with the provisions of T 5 of The State Sanitary Code y ale` bed in the // G . application for Disposal Works`Co struction Permit No. ___-. --_---��.�i....__...... dated_ ....7_................. ............... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM W LL FUNCTION SATISFACTORY. DATE A%--•�............................ Inspector.. - _ "`' ----------•---------------.-......:- } THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH. O�VfK... ..............OF......,/ a�........'�_.dt ' 4 ............................... N FEE...!SP........... Disposal Works Tontnutuan rumit 7X4.Permi'ssion is hereby granted..................................''. a...u _tf-�-✓`'`�......�� �� to Construct-;(�,or Repair ( ) an ndividual S .wage Disposal System ' at No......X- � � ............ i ll fist.?�c. ��.r�.�t/f'--- - Street as shown on the application for Disposal Works Construction Pe ) No...._ Dated......77: .7�---....... aG Board of Health DATE-----��.------•------•.-----••. --••--•---•----•--•..............: FORM 1255 HOBBS & WARREN. 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