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HomeMy WebLinkAbout0000 NARROWS WAY - Health r,�O Narrows Way Cotuit ,P= � ���:', CO i U I A --021;,-003003 f ;i a i NOTICE: The Town of Barnstable recommends_that the annlirant I seek legal advice to prepare a- properly worded deed i restriction document. DEED RESTRICTION ; WHEREAS, A XXANA 6X t/ks l f f/� kvm 0b� ///V ofAIC ' (owners name) MA j (address) is the owner of located I atddress) CO(/O�f 7 i MA (hereinafter referred to as WAY and being shown on'a plan entitled "Subdivision of Land in l p2A��, MA, Property of L /Vlf► /f� ©.S / ' et al, lob-9 QAQ 61 i Mfg duly recorded in Barnstableounty Registry of Deeds in Plan Book mO , Page aJ R q C Or on Land Court Plan Number WHEREAS, — AM 6 Q as t owner of said lot has (owners name) V Hll� agreed with the Town of Bamsta a d'ard o �ea�th'to a restriction as to the number of bedrooms which can be included in any home built on said lot as a pre-condition to obtaining a disposal works construction permit in compliance with 310 CMR 15..000 State Environmental Code, Title V, Minimum Requirements for the Subsurface Disposal of Sanitary Sewage; WHEREAS, the Town of Barnstable Board of Health, as a pre-condition to granting a disposal works construction permit for a septic system in compliance with 310 CMR 15.200, State Environmental Code, Title V, Minimum Requirements for the Subsurface Disposal of Sanitary Sewage, and authorizing the issuance of a building permit for the construction of a single family home on this property, is requiring that the agreement for the restriction ors-the number of bedrooms in any house constructed on the lot be put on record with the Barnstable County Registry of Deeds by recording this document, deedr NOW, THEREFORE, / 1AWMiddles hereby place the �A�'M V��cylAl following restriction on his above-referenced land in accordance with his agreement.with the.T_oad n of big of Health, which restdction sha* run with the land and be binding upon all.successors in title: �Q &4ff&Ls a Aq r o7-�t/r,/�/�/,, may have constructed (address) upon the lot a house containing n more than �+�c3) bedrooms. ' qldagrees that this shall be permanent deed (owners name _ restriction affecting located on G'QS1/MA, and being shown on the plan recorded in Plan Book a Paged .3a Or on Land Court Plan For title of YONIM&'Of ( 2&see the following deed: Book IA Page _ . Or Land Court Certificate of Title Number Execu e�as a'.sealed nstrumen day of e Owner's signature Owner's signature Owner's signature COMMONWEALTH OF MASSACHUSETTS . ss 20_ Then personally appeared the above-named known to me to be the person who executed the foregoing instrument and acknowledged . the same to be' free act and deed, before me, Notary Public My commission expires: (date) dmdr BAWTABLE;REGISTRY • RECEI ED COMMONWEALTH OF MASSACHUSET':'S SUN 0 4 2003 EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS TO�NN of e DEPARTMENT OF ENVIRONMENTAL PROTECTI HEALTH pEPTABLE F � C A yA Q V TI TLE 5 OFFICIAL INSPECTION.FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 40 NARROWS WAY COTUIT,MA 02635 ��� Z> C Owner's Name: ROSE CAVANAUGH Owner's Address: 40 NARROWS WAY COTUIT,MA 02635. Date of Inspection: 5/5/03 Name of Inspector: (please print) JOHN GRACI,INC. Company Name: SEPTIC INSPECTIONS Mailing Address: P.O. BOX 2119 TEATICKET,MA.02536 Telephone Number: 508-56476813 FAX 508-564-7270 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 the inspection.The inspection was pei formed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: X Passes _ Condition9 I Passes _ Needs Fuj r Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: 5/5/03 The system inspector shall subm a copy of this inspection report to the Approvin Authority(Board of Health or DEP)within 30 days of completing this inspe 1 tion. If the system is a shared system or has a design Plow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the apprm ing authority. Notes and Comments SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. ****This report only describes conditions at the time of inspection and under- the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 40 NARROWS WAY COTUIT,MA 02635 Owner: ROSE CAVANAUGH Date of Inspection: 5/5/03 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: SYSTEM PASSED TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. B. System Conditionally Passes: _ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. n/a The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: n/a n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): _ broken pipe(s)are replaced _ obstruction is removed _ distribution box is leveled or replaced ND explain: n/a n/a The system required pumping more than 4 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 ND explain: n/a Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 40 NARROWS WAY COTUIT,MA 02635 Owner: ROSE CAVANAUGH Date of Inspection: 5/5/03 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 public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,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 any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance n/a "This system passes if the well water analysis,performed at a DEP certified laboratory,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,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: n/a Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 40 NARROWS WAY COTUIT,MA 02635 Owner: ROSE CAVANAUGH Date of Inspection: 5/5/03 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all-inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than 'h day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped nLa. X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _ X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ X 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. [This system passes if the well water analysis,performed at a DEP certified laboratory,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 P Y less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] NO (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X 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 If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. a Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 40 NARROWS WAY COTUIT,MA 02635 Owner: ROSE CAVANAUGH. Date of Inspection: 5/5/03 Check if the following have been done.You must indicate"yes" or"no" as to each of the following: Yes No X _ Pumping information was provided by the owner, occupant,or Board of Health _ X Were any of the system components pumped out in the previous two weeks? X _ Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out? X _ Were all system components,excluding the SAS,located on site? X _ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no X _ Existing information.For example,a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] S Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 40 NARROWS WAY COTUIT,MA 02635 Owner: ROSE CAVANAUGH Date of Inspection: 5/5/03 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):330 Number of current residents: 2 Does residence have a garbage grinder(yes or no): YES Is laundry on a separate sewage system(yes or no):NO [if yes separate inspection required] Laundry system inspected(yes or no):NO Seasonal use: (yes or no): NO Water meter readings, if available(last 2 years usage(gpd)): n4r- ' 4, U00 Sump pump(yes or no): NO I� Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sqft,etc.): n/a 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: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: n/a Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/agallons--How was quantity pumped determined?n/a Reason for pumping: n/a TYPE OF SYSTEM X 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) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach a copy of the DEP approval Other(describe): n/a Approximate age of all components,date installed(if known)and source of information: DECEMBER 1993 BY OWNER Were sewage odors detected when arriving at the site(yes or no):NO F Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 40 NARROWS WAY COTUIT,MA 02635 Owner: ROSE CAVANAUGH. Date of Inspection: 5/5/03 _ plan)BUILDING SEWER locate on site ( Depth below grade: 22 Materials of construction: cast iron,=40 PVC_other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade: 16" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 1500 GALLONS! Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle:32" Scum thickness: 2 Distance from top of scum to top of outlet tee or baffle: 6 Distance from bottom of scum to bottom of outlet tee or baffle: 16" How were dimensions determined: MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. GREASE TRAP:_(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a, Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): n/a Page 8 of l I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 40 NARROWS WAY COTUIT,MA 02635 Owner: ROSE CAVANAUGH Date of Inspection: 5/5/03 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no):NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX: X(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover,any evidence of leakage into or out of box,etc.): D-BOX WAS VIDEO INSPECTED AND APPEARS TO BE STRUCTURALLY SOUND. PUMP CHAMBER:_(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a u Page 9 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 40 NARROWS WAY COTUIT,MA 02635 Owner: ROSE CAVANAUGH Date of Inspection: 5/5/03 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type 1000 GAL 6' X 6' leaching pits, number: 2 n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a innovative/alternative system Type/name of technology: n/a Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): LEACH PITS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.SYSTEM SHOWS NO SIGNS OF FAILURE. Goo 03' 0 � , CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(conti=A) Property Address: 40 NARROWS WAY COTUIT,MA 02635 Owner: ROSE CAVANAUGH Date of Inspection: 5/5/03 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.Locate where public water supply enters the building. . A � Q e E o AA A6 3( 11CP jq> RC q CA 41 b , Lc 30 C� 1L in page I 1 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 40 NARROWS WAY COTUIT,MA 02635 Owner: ROSE CAVANAUGH Date of Inspection: 5/5/03 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 12 feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from systg1m design plans on record- If checked,date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) NO Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: HAND AUGER- 12 FT. TOWN OF BARNSTABLEp- 1 LOCATION SEWAGE # VILLAGE 0lQ—j Li 1 7- ASSESSOR'S MAP 6��LOT i g 1 �6 INSTALLER'S NAME 6a PHONE NO. . L i ri+ZVi3"i Vi v:-ILA SEPTIC TANK CAPACITY.. 0r4 ' - J LEACHING FACILITY:(type) .(size) 1000 � (� NO. OF`BEDROOMS s PRIVATE WELL OR PUBLIC WATERLC BUILDER OR OWNER �TJ �L! f� DATE PERMIT ISSUED: 5 DATE COUPLIANCE ISSUED: VARIANCE GRANTED: Yes No t/ v 4.r 3 Nof �?.�` -.h THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEAL H ....................... ................OF...... ... --- ...._...._s�-..................... Applira Linn for Uiipnsal Works Cfnnstrnrtion ramit Application is hereby made for a Permit to Construct (ojror Repair ( ) an Individual Sewage Disposal System at .. Location-Address or-lot No. ...... 4......*/ ner V --------------------•-•.... ---- t._. ... .------. .. ..... 1 Install Address S� Type of Building Size Lot:... ............ . .... q. feet Dwelling—No. of Bedrooms____... . -__ Expansion Attic ( ) Garbage Grinder aOther—Type of Building .� .. No, of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures --------------•---------•------•-----------•----------------------•--•--••••----•-•-----•----•--••-•--•-------••.................................... Design Flow.................................. gallons per person per day. Total daily flow............................................gallons. W ),r WSeptic Tank—Liquid capacityl�.-�-gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No..__.�1.�Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No-----_------------- Diameter.................... 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........................ G14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-------_................. 9 -•..........................•---------------------------------------------------------•-•--•......•...... --------------------- -------------------------- ••-- 0 Description of Soil.......................................................................................-................................................................................ W c, ---•••---•••--------••-------•--•--------------•----•-•-----......-----------------------•-•-------•---------------------------------•••-----------•-•--••••........................................... 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 TLE 5 f the Stat anitary Code— The undersigned further grees not to place the system in operation until a ificate f e e n issued th rd of h 1 igrie ..... ---- . . ------ . --- ......................... -•-------..✓ •..... D tq1�—� Application Approved -------- .... 1 .. -- - -------------------- ..���'' .. .... Date Application Disapproved for the following reasons-------------------------•----•-----•--------------------------•-•-----••.....-•---------•---•••--------.--•--- ........................................................•.._....•----------------•....-----••-----....--•------------------•-••----••••---••--•----••---------------••--•----•--••-----••---......-•--- �y Da Permit No...1...-��"..4 �JL ...... Issued__.... � �—�,3 ...................- Date a t t G 'i. > f[/ i 1 • No.,p .0 Fss ....._... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ... G � F � ...... . ................... Appliration for Disposal Works Toustrudiou frrutit Application is hereby made for a Permit to Construct (4'`or Repair ( ) an Individual Sewage Disposal System at• 1 ..-... /....o.r. ' ...... ........ .... --.. - .- --- Location-Address J / Lot No. Ad ess/ f al l Installer Address Type of Building Size Lot....�'�� .....Sq. feet Dwelling—No. of Bedrooms.......a n.......-:._T................Expansion Attic ( ) Garbage Grinder A4 Other—T e of Building /5A'41 �. No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures -----•------------- f•-•••-••--------....-•..............................------------------------.--------------•-------------•---------- W Design Flow.................................rr_�.......__gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid*capacityl�. .gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No._, _f ✓'. "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........................ C14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 •-------------------------------------------------------- •.................. ........ .--•------------ ------- ------------ •------------ •......... ---------- --•-- 0 Description of Soil....................................................................................................................................................................... ... ---------------------------------------------------------------------------- -------------------------------------------- •----------------------------- -....... ---------- --------- •------ --•-----..... 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 5 f the tat anitary Code—The undersigned further agrees not to place the system in operation until fica.te f e issued he.board of lie It 4 Y. f P ' igned ..........�---= ="' i`'.- ............ ate scr....-......._ Application Approved B -•....•. •• • -- •... ••.'.r.•---.. td.... - --•--••--•--Z----•-------•. .... "-'/-.J ----...... Date Application Disapproved for the following reasons---------------••-------•---.................................................................................. --.......-•-----•---------------•--•--...----••-------•---•---•--•-----•------•••-•-----........-•------•.....-----------------------••-•-----••••-----•...•-•-----•----•-•-•---•--•-••--•--....-•-•---•- Permit No..-_1 � .__. Issued......./G •--•--•---------------------------------- ...`................................ Date THE COMMONWEALTH OF MASSACHUSETTS _ BOARD OF HEALTH rr"Lll`Y............OF....... ........................ C9rdifiratr of faomliliatta THIS IS?Q CERT FY, hat the Individual Sewage Disposal System constructed ( Wor Repaired ( ) by.. ..... ----- Instalr �. ---....._..-•--•-----------•----- at •4.. j------------------------------------------------------------------------ has been installed in accordance with the provisions of TITIE 5 of The Sgate Sanitary Code as descr . ham., application for Disposal Works Construction Permit No.__��' ._.. .. dated----l : '"'_f�%__"''l_..:. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.................. _.'_ ""-.-------••--_-•------------ Inspector....---...... ,_1.. .................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No.. �' .. -.. .f�..� <..........OF..... .. .... �7 ...... . Roposa or s Tons#rudion rrmit Permission is h re by granted.. ................. '` .. ... •------•--••----•---••--••-•-----------.........•--•.............---..�. to Construct ( r Repair ) an Indivi a ewage D'spos S tern f�. at No.. t''i✓ .11� .ram. ....,�7�.. td/---.... ...... c�'' 'CJ r .. Street ���� ,�• as shown on the application for Disposal Works Construction Pe it No._t:,.-,1-_'.� ted_ �0 1 _ O ^ Board of Health DATE............... -......................-• ------------------ _.. FORM 1255 HOBBS & WARREN. INC., PUBLISHERS TJE5161J -PATA - 51146LE FAIAIL`( 3 $EVIEW 44' LY 6AIaAr- &Zgvm aas//j .PAILS FLOW 3 x►to _ 330GV7 SE'Pi'l C TA►JIL 330 x t 9C� =�►�sGPD ,.,. .� � f�•CY�S�,.g 51.4 lyip Isoo _PIS?oSA L PIT I- 1 000 1-A roNc a Imo, 2q 511;>EWACL AvaA - Vz& sF I s I 43, 01 Zw,SF )X 7•S =- 5'5 e.i'D, i1 il, BOTTOM AZA = i 13 s F i_ _► TFTTAL tev6W = G%S 6{fi, 'TorAL DA I L. 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