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HomeMy WebLinkAbout1136 OLD POST ROAD (CT & MM) - Health 1136 OLD POST bAD� f A=056-010 I �j No. v / 1 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ko- PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01pplitation for -Disposal 6pstpm ConstCULtion 3pPrmit Application for a Permit to Construct( ) Repair N Upgrade( ) Abandon( ) ❑Complete System X Individual Components Location Address or Lot No. 113 6 04--t> POST P40A?> Owner's Name,Address,and Tel No. 4co-rukt j MAPtC + ZTAIJ6T L d A)�f-W l Assessor's Map/Parcel 0,5(® 11 OLD PPS( P— C,d` u t-r Installer's Name,Address,and Tel.No. Designer's t! _�,$`( � Designer's Name,Address,and Tel.No. dA0r-- J(n6 eN)TW4J365 i Lc- P� N /A Type of Building: A Dwelling No.of Bedrooms /V Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Q Design Flow(min.required) /�/( gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) S(Qr(-L— e)L),TL I= TE5 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 Certificate of Compliance has been issued by this Board of Heal ` Si ed Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No.7.o(6 Date Issued , Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in compute PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 2pplication for Bisposal 6pstem Construction permit Application for a Permit to Construct( ) Repair(O Upgrade( ) Abandon( ) ❑Complete System X Individual Components Location Address or Lot No. I 15(,p 04-0 P®S'T P44b Owner's Name,Address,and Tel.No e f4 Assessor's Map/Parcel Q 5(p 01 0 CoTu�l(M,� 11 (,off O C.b (COST PL D C T U I T Installer's Name,Address,and Tel.No. 509_477 . �$11 Designer's Name,Address,and Tel.No. CApew(D O 1=r zW4j s6S i,/_c. tv fA Type of Building: Dwelling No.of Bedrooms N� Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures n Design Flow(min.required) A) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: _Z&1 (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 Certificate of Compliance has been issued by this Board of Healt_. Signed Date Application Approved by Date 47 Application Disapproved by Date for the following reasons Permit No.7,o/( y Date Issued ------------------- ------------------------------------------------------------------------------------------------------------ THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO RTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( Upgraded( ) Abandoned( )by 14 (�2(rj ���G'. �< �.�. at ? -E� -��� (ZMf T IN has been constructed in accordance with the provisions of Title'5 and the for Disposal System Construction Permit NO.;&b 9 dated �kglza, Installer Owe(,ylbr-- � L.G�i Designer Iy/J4 #bedrooms A Approved design flow. gpd The issuance of this pe it s.fall not be construed as a guarantee that the system will func Vim- dr igned. Date S ��f Inspector ---------------------------- ----------------------------------------------------------_---------------------------------------- o� No.20 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Bisposal 6pstem Construction hermit Permission is hereby granted to Construct( ) Repair(x) Upgrade( ) Abandon( ) System located at I I _ (D L) P&�;-T ,R a A-0 and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Co tructi n must be completed within three years of the date of this permit. D, Approved by TOWN O�F/BARNSTABLE �D LOCATION �IJ� iv ®J� /6'�. SEWAGE # VILLAGE a ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. ®� � � ��� 77/ SEPTIC TANK CAPACITY Ode) Dti Pj LEACHING FACILITY: (type) f V d Gk (eac 4 (size) /01•S�X 5.�.7 NO.OF BEDROOMS BUILDER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 �i13� \ .; � �� Fro+ � � r �9� ;� r � � - �� � `b ���� �• � Q ..,�.: ��• ��, �; o ,, O p r4 ,- O � � n , . • 1\io. c/ -7-6 Z 8 Fe THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: _L Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01ppfication for Migooar bpotem Construction permit Application for a Permit to Construct( )Repair(✓)Upgrade( )Abandon( ) ❑Complete System [P"Individual Components Location Address or Lot No. / 2� olv Ae,/ — Owner's Name,Address and Tel.No. �7 ��r// Assessor's Map/Parcel CLIP IV/ Bid ��e Installer's Name,Address,and Tel.No. l Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder(4p Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow Ille5l gallons per day. Calculated daily flow 330 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank /®®V Type of S.A.S. ,�0� Description of Soil Nature of Repairs or Alterations(Answer when applicable) �� t`% z1f 0.0/ 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 Jw thi d oMiealth. Signed Date /eM Application Approved by Date Id-10 7 Application Disapproved for the following reasons Permit No. Date Issued ——— ————— �. 7:G _ _ Fee��y �d Entered in computer: THE COMMONWEALTH OF'MASSACHUSETTS v:W Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 2ppricatio,n for Migpogal *pgtem Congtruction Permit Application for a Permit to Construct,( )Repair( V)Upgrade( )Abandon( ) O Complete System Ck`Irtdividual Components Location Address or Lot No. / o�� r�5 / , Owner's Name,Address and Tel.No. Bid �u�r//mil e Assessor's Map/Parcel ,y Installer's Name,Address,and Tel.No. / Designer's Name,Address and Tel.No. Type of Building:Dwelling No.of Bedrooms 17 Lot Size sq. ft. Garbage Grinder / 0 Other Type of Building Re S/ 0WCG No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow /6D gallons per day. Calculated daily flow gallons., Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Soaq�r ��Aa • ��,-5 Description of Soil Nature of Repairs or Alterations(Answer when applicable) 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 Certih cate of Compliance has been issued thi d o ealth. / Signed 7 AO Date A lication A `roved b - Date to-+o-9 PP PPt y 'Application Disapproved for the following reasons Permit Not 7- G 2 Date Issued /0"3G-9 7 THE COMMONWEALTH OF MASSACHUSETTS D 5� BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CE TIFY,that the On-site Sewage Disposal System Constructed ( )Repaired(P-5 Upgraded( ) Abandoned( )by 4VI A0 at //J d �.� 10/� ® / has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 97-G Z6 dated ©-30 0/7 Installer Designer The issuance of this ermit shall not be construed as a guarantee that the syst ill fuunctio as designed. Date 11"-7- �7 Inspector , -/ F: ---------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS lwigaal bpgtem onotrurtion Permit Permission is hereby granted/to Construct( )Re air,( Upgrade( )Abandon( ) System located at '113 d ale �h' Go;,'wl7— 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 becompleted within three years of the date of this permit. Date: G —3 U - / Approved by - -, t - i 10/9/97 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT ENGINEERED PLANS) I, ��de/'y`(j•• ,�®ram /, hereby certify that the application for disposal works construction permit signed by me dated /O�Z���7 , concerning the property located at 113d ®1������ ����� meets all of the following criteria: '1✓ here are no wetlands located within 100 feet of the proposed leaching facility here are no private wells within 150 feet of the proposed septic system There is no increase in flow and/or change in use proposed ere are no variances requested or needed. If the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the proposed leaching.facility will aat be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation. Please complete the following: Z A)Top of Ground Elevation(according to the Engineering Division G.I.S.map) B)Observed Groundwater Table Elevation(according to Health Division well map) L DATE: SIGNED: LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. q:health folder:cert TOWN OF BARNSTABLE LOCATION ��J�h D/ �OJ 7�/Or: SEWAGE # 7�� ' ":':YILLAGE�C�,�//h ASSESSOR'S MAP & LOT-, INSTALLER'S NAME PHONE NO. �O�7�L0 / �O�f'c5 77/—64 Q��� ME :..SEPTIC TANK CAPACITY /0w LEACHING FACILITY: (type) !?7 d Cl G'4 ��c y wdl.U (size) 'NO.OF BEDROOMS— :-BUILDER PERMITDATE:1��--�--; COMPLIANCE DATE: :;:::Separation Distance Between the: ::Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Sf' Feet ::'Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) /5-0 Feet ::Edge of Wetland and Leaching Facility(If any wetlands exist -/ > Feet within 300 feet of leaching facility) :.::Furnished by O O O I i /g-, 1' Town of Barnstable Department of Health, Safety, and Environmental Services DAMSTABIA M^� Public Health Division pTFD^^�a 367 Main Street, Hyannis MA 02601 Office: 508-790-6265 Thomas A.McKean FAX: 508-775-3344 Director of Public Health February 6, 1997. William Mary Everett P.O. Box 418 W. Hyannisport, MA 02672 ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL CODE, TITLE 5. The septic system owned by you located at 1136 Old Post Road, Cotuit was inspected on January 27, 1997 by Robert Bortolotti a Massachusetts licensed septic inspector. The inspection of your septic system showed that your system has failed under the guidelines of 1995 TITLE 5 (310 CMR 15.00)due to the following: • The cesspool was full of wastewater. You are directed to hire a licensed Town of Barnstable septic system installer to submit a sketch diagram of a proposed system to the Town of Barnstable Health Division Office (Town Hall, 367 Main Street, Hyannis)that will bring the septic system into compliance with 310 CMR 15.00, the State Environmental Code, Title 5 within (14)fourteen days of receipt of this notice. You are also directed to bring the septic system into compliance within thirty (30) days of receipt of this order letter. You are further directed to maintain the system by hiring a licensed septage hauler to pump the septic system to prevent discharge of sewage or effluent into the buildings, onto the surface of the ground, or in to surface waters. Any person aggrieved by any order issued by the local approval authority may appeal to any court of competent jurisdiction as provided for by the laws of the Commonwealth. PER ORDER OF THE BOARD OF HEALTH omas A. McKean, R.S., C.H.O. Agent of the Board of Health gym ,, Town of Barnstable • Department of llealth, Safety, and Environmental Services c M health Division 367 Main Street,Hyannis MA 02601 Installer 7lweue A.McKeon OIII¢e.-50�90-6265 Dimclor of Public Hahh I:AX: 509-775-3344 IN 1(� (41� -. —G` TO: (Date) � 0 a673.M�- ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL CODE, TITLE 5. The septic system owned by you located at 11.36 6 Avenue, Circle, Lane, Road, Street in the village of Ce was inspected on / ,-:,7- f7 by `„�,, a Massachusetts licensed septic inspector. The inspection of your septic system showed that your system has failed under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: You are directed to hire a licensed Town of Barnstable septic system installer to sketch a proposed system that will bring the septic system into compliance with 310 CMR 15.00, The State Environmental Code, Title 5 within (14) fourteen days of receipt of this notice. The septic system must be brought into compliance within thirty (30), sixty (60), ninety (90) days of your receipt of this letter. You are also directed to maintain the system by hiring a licensed septage hauler to pump the septic system to prevent discharge of sewage or effluent into the buildings, onto the surface of the ground, or in to surface waters. Any person aggrieved by any order issued by the local approval authority may appeal to any court of competent jurisdiction as provided for by the laws of the Commonwealth. PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean, R.S., C.H.O. Agent of the Board of Health Town of Barnstable title 5(1) ] PAR ] Real Estate System - General Property Inquiry] Help [ ] Parcel Id: 056 010- - Account No: 31986 Parent : Location: 1136 OLD POST RD COT Neighborhood: 09AA Fire Dist : CT Devel Lot : 54 Lot Size: . 73 Acres current Own: EVERITT, WILLIAM T & MARY T State Class : 101 K & B TRUST No. Bldgs : 1 Area: 3888 PO BOX 418 Year Added: W HYANNISPORT MA 2672 Deed Date : 080190 Reference : 7244/283 January 1st : EVERITT, WILLIAM T & MARY T Deed MMDD: 0890 Deed Ref : 7244/283 Comments : Values : Land: 69500 Buildings : 225200 Extra Features : 21800 Road System: 1136 Index: 1165 (OLD POST ROAD ) Frntg: 153 Index: ( ) Frntg: Control Info: Last Auto Upd: 050695 Status : C Last TACS Update : 112090 Land Reviewed By: Date : 0000 Bldgs Reviewed By: Date : 0000 Tax Title : Account : 4997 Taken: 120893 Account Status : Hold Status : Cancel [ ] Press XMT for more data Next screen [PAR ] Action [ ] Owners Name [ ] Road Index [ ] Road Name [ ] Parcel Number [056] [011] [ ] [ ] [ ] TOWN OF BARNSTABLE �0U!la LOCATION 0,36 0 ) ,A s 9L d o ri d SEWAGE # VILLAGE ASSESSq'S MAP&LO(T Q 0. SSA ?"NAME&PHONE NO.< r'/0 16 U SEPTIC TANK CAPACITY LEACHING FACILITY: (type) 1 / J (size) 0 401 NO.OF BEDROOMS BUILDER R OWNED�� G 'I� (Jallgce' PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 OL/- ,�"" �� //� i NO .f BORTOLOTTI-CONSTRUCTION,.INC. • 4 j f 765 WAKEBY ROAD,MARSTONS MILLS,MA 02648 Z 508-771-9399 508-428-8926 FAX: 508-428-9399 r" SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FO G PART A CERTI FICATIO Property Address j 1-,3L Date of Inspection: - ' ). 1'�) Inspector's Name: . ,L - O wn ees Name ap4 Address: _ a CERTIFICATION STATEMENT! I certify that I have personally inspected the sewage disposal system at this address and that the informa tion reported below is true,accurate and complete as of the time of inspection. The inspection was per- formed 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 Eva ation By the Local Aproving Authority Fails Inspector's Signature: Date: 711f7 The System Inspector shall submit a copy of this inspection report to the Approving authority within thir- ty(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 1MMARY• A)SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CM11 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. Tile system,upon comple-, tion of the replacement or repair, passes inspection. Indicate yes,nor,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 sep- tic tank is replaced with a conforming septic tank as approved by The Board of Health. Sewage backkup 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): SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) P•' t rt 0 Broken pipe(s)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 C)FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by The Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1)SYSTEM WILL PASS UNLESS BOARD.OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 Feet of a surface water Cesspool or privy is within 50 Feet of a bordering vegetated wetland or a salt marsh. 2)SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTION- ING 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 with 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 the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less s than 5 ppm. D)S TEM 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 sho*be contacted to determine what will be necessary to correct the failure. t/ Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of efluent 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 clog- ged 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 -2- ti; 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM PART A CERTIFICATION (continued) 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 acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E)LARGE SYSTEM FAILS: The following criteria apply to a large system in addition to the criteria above: The design flow of a system is 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 within400 Feet of a surface drinking water supply The system is within 200 Feet of a tributary to a surface drinking water supply The system is located in a nitrogen sensitive area Interim Wellhead Protection Area (IWPA)or a mapped Zone II of a public water supply well. . The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Check if the following have been done: 'limping information was requested of the owner,occupant,and Board of Health. None of the system components have been pumped for atleast 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. J/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 site. Ij The septic tank manholes were uncovered,opened,and the interior of the septic tank was in- spected for condition of baffles or tees,material of construction,dimensions,depth of liquid, depth of sludge;'depth of scum. - - l� The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. -3- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST(continued) E/The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION--,. FLOW CONDITIONS Design Flow: ?f allons Number of Bedrooms:' Number of Current Residents: Garbage Grinder: AA( Laundry Connected To System: rS Seasonal Use: a)(') Water Meter Readings,if Mailable: Last Date of Occupancy: .LC,/�2 cox o< COMMERCLAL11NDUSTRIAI Type of Establishment: Design Flow: aallonstday Grease Trap Present: (yes or no) . . . Industrial Waste Holding Tank Present: Non-Sanitary Waste Discharged To The Title V System: Water Meter Readings,If Available: Last Date of Occupancy: ' OTHER: Describe) Last Date of Occupancy: GENE INFORMATION PUMPING RECORDS and source of information. L System Pumped as part of inspection:, )/L O If ye ,volu a pumped: gallons Reason for pumping: TYPE OF SYSTEM: Septic Tank/Distribution Box/Soil Absorption System Single Cesspool . Overflow Cesspool Privy hared System(If es,attach previous inspection records,if a ) �/OtherAexvlain) ? ? "a % i, , (. Z i-IEVs APPROXIMATE AGE of all components,date installed(if known)and source of information: Sewage odors d tested when arrivin at the site:�4A) -4- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C GENERAL INFORMATION (continued) i . SEPTIC TANK: IIc.��$�� Depth below grade: Material of Construction: concrete metal FRP. Other (explain) — Dimisions Sludge Depth: Scum Thickness: Distance from top of sludge to bottom 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,etc.) GREASE TRAP: 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: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles;depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,etc.) . t TIGHT OR HOLDING TANK: Depth Below Grade: Material of Construction:_concrete_metal—FRP Other(explain) Dimensions: Capacity: Gallons Design Flow: gallons/day Alarm Level: Comments: (condition of inlet tee,condition of alarm and float switches, etc.) DISTRIBUTION BOX: 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 CHAMBER:/ R_ Pump is in working order: Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) -5- x SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C 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: Leaching pits,number:Leaching chambers, number: Leaching galleries,number: Leaching trenches, number,length: Leaching fields, number,dimensions: Overflow cesspool, number: Comm ts: (note condition of soil signs of hydraulicfailure level of pondin ,condition of vegetation, etc.) � ) C.P; • � '' ' '� ��.� ��i'` l[Rc'�"� d c CESSPOOLS: Number and configuration: Depth-lop 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 soilk, signs of hydraulic failure, level of ponding,condition of vegetation, etc.) PRIVY:_L Materials of construction: Dimensions:_ Depth of Solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.) -6- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references, landmarks or benchmarks. Locate all wells within 100 Feet. ct i DEPTH TO GROUNDWATER: , Depth to groundwater: /;S Feet �/ Method of Determination or Approxi tion: /¢ l��'��ICr � /;.o k7 k .V Y LOCATION 5 S E A G E PE RVIT p0. VILLAGE INSTA LLER'S_ NAIVE 0 ADDRESS /9 { BUILDER OR 0013ER (,� ., DATE PECIMIT ISSUED 112- DAT E" C0MPLIAPICE ISSUED l ' a v 5,�.-�-Te Fizs.. / THE COMMONWEALTH OF MASSACHUSETTS .�, BOARD OF HEALTH A.QWIA .._------------- oF.:... /�����1����-...................................... Appliration for Bispviial Warkii Tontitrurtion runfit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ................_..........a .....pq- .,T---...1�4. .......:4 :i�.G�"....... ...... --4- ..... ............................... Location-Address b or Lot No. ---......�{' f 1_i,. V 12\-T`i ......... i�_ HluiUrS I: `H:r�'-�-=•�Z�. Owner Address Installer Address Type of Building Size Lot__........_. --- ...Sq-fm aDwelling—No. of Bedrooms................._q......................Expansion Attic (�) Garbage Grinder ( ) p, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures -------------------------------•• -� - ----- --------..........---------------------------------------------------------------------.._......------- Design Flow...................S5._._.. ____.____ gallons per person per day. �C�Total daily flow.._......_....._....31:�............ WSeptic Tank—Liquid capacity Length................ Width................ Diameter-----------__--- Depth................ x Disposal Trench—No..................... Width__ t....__._._._ Total Length................._..Total leaching area....................sq. ft. Seepage Pit No.........t---------- Diameter____________________ Depth below inlet.....CR.......... Total leaching area...10.0..sq. ft. _Z Other Distribution box (K ) Dosin tank ( )1-4 ~' Percolation Test Results Performed b _.t.J...6.... .._ "•��� .. Date.......... ....... ' Test Pit No. I........Z--..minutes per inch Depth of Test Pit-------tom,..--• Depth to ground water----`7=........ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 •---•-•-••------------------•-------........•-•-..........-•-----•---•••._._........--------•.--............................................................. 0 Description of Soil................... vi 4%' -----•.... A1J -----------------•............_._..... 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 iITI,% 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 f-health Signed-•C --------- --------- 3 ! / Date. Application Approved BY-•-•-•• te - - ................................ ..`....... Date Application Disapproved for the following reasons-------------------------•----•---•--•-------•-----------------------------•------------------------------------- .......................................••-•---••---•--•-••••................----•----•-...._......-••-------•-••••-•--•-•--•••--•-•••--•-••••---•••....-------•--•-----•-------•---•-•-•-•-•--••-•----- Date PermitNo......................................................... Issued............_....-----......-•-•--......................... Date zFxs..........................._ THE COMMONWEALTH OF,,MA SACHUSETTS .�_ BOARD OF HEALTH ..................OF... .. tL ( .... :-. . --- Appliratiou for Disposal Works C onstrurtion Vamit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: l) ...........................`.:l i `....' ," lt`C: `a _ t,11 r--•--..._......................... � � '................____....._...... ....... •.......... ............................ Loeation.:.Address - To } t t t. a or Lot ............................................•-----•-----....-------•--•-•--....................... ..........".......---•--............----•-----__... ...........................................MASS, Owner Address ] a •_____..-•........................................•.•.........................._................ ..................................................... _...__. ........................... Installer Address UType of Building Size Lot.._:2=....!"-C-.......Sq—"feet Dwelling—No. of Bedrooms................._._.._.___._____.......Expansion Attic ( ) Garbage Grinder ( ) a` Other—T e of Buildin 4 yp g ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) d Other fixtures . ........ ; W Design Flow....................2.5.._....;............gallons per person per day. Total daily flow............................................ ' v.___.__....gallons. WSeptic Tank—Liquid-capacityC_t?...gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width......j............. Total Length...........,....... Total leaching area....................sq. ft. Seepage Pit No.........t----------- Diameter............-'___._._. Depth below inlet.... ............ Total leaching area.•c ...sq. ft. Z Other Distribution box (K ) Dosing tank ( ) I I ; `" Percolation Test Results Performed by�..._'...�_..__..'._h`L....�!�.....�'._)C`:�C`:_ �� Date.....•....I.Z...-.__`�%� Test Pit No. 1........ ..._ ?—'......minutes per inch Depth of Test Pit ... ..... Depth to ground water........................ (T4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water......._................ ......................... Descriptionof Soil...................-##.........-------------•.......-`=-----•----•-------....----------------•-----•-----•---•-•------.....----•--------•-•---------•--•-••.....---- id . lt>i��ti � V ....................• ............................................................................................... W 1 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 iT 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been s d by tljrbVa healt Signed...-. --- .....;. . .... -•----•---....----•....----•...-------•-• �. Application Approved By.......... •--•----••---••-•-•---------- Date Application Disapproved for the following reasons--------------------•-------------------•------•-----•--------•------------------...--------•----•----....._._. -•.....................•----••--------•-----•-----••---------......------....-----------•------....--------------------...-•-----------•---••....-•-•--------•-------•-- ............................... Date PermitNo......................................................... Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 4� °r ✓l,t i 1 s > ( �t iT gym ....... ............................OF...... ......................................................................... %lun if iratr of Toutpliaicrr THIS IS 10 CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by ...... Of `... .:..._ ----------------------------- at.---•--------••-----------------------•-•----------....-----------•-----•--------...._ has been installed in accordance with the provisions of T811 -j" The State Sanitary Code as described in the application for Disposal Works Construction Permit No._..................................... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE. .l.i� ....`.... Inspector...........................cam' ....................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........�.Ct,(-Di .................OF........ %. .IC.t..••3• -..Gc, 5F�......................................... No......................... FEE........................ 111VII 9mrhaw1rudialt Vantit Permissio�s hereby graQd............................................................................................................................................. to Construct?'F' ) epairn I gg.Disposal System atNo... ............ .... Street as shown on the application for Disposal Works Construct mit To.__ Re / at ............ Board of Health -------------------------------------------------------- DATE.............=...... - •�--�--�-�-�"''-•' FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS St+.1G1_t✓ FAMtL?! - 3'�3mtzoo�K i_. ' uo GArZIMAr tr T>&tL%.( Low = 1to +c 3 • 33o � -Pr1C -rA4.IK W. S30d IBC p: • CIS 6.RD. f U Ste- t CCU 61t.1.. : ..l . �L&tJ _ 01 �715POS,�t PtT u�.E l Doc Gam. 1 P0zr l o .� C�' �Ur,;WA L AeeA l'So S- P. I o7 s4- . :� k lc>p SF Z..S • 3"7S 6.P.D. �ol.l�.. =l � AzeAv l .o TOTAL -Pe616W = .426 wTo mat t.�f t=Lvw z 330 6�P.v. , Tor >'wo ids 9 2 i r.—n�:7*i t `n 4 p .. ....i�• tug•9/• oAM +- -p,.pe Iooa lug 2� `box 9o•& Sync . ram• � I�� l �A W loco qa llwv, tw •t• 4;w .. . GAt.. : 9o•Z... 90.. :. LsAao .. PIT W I wns++aa I . .__ . to _.-- -•._.... .. . . ..___ .. . ..�._.._,___ .__-_-..:.._--�-- �---- - - CEC'•CIFiED pL0"T' Pt_. �] F419 . . LoCATlo" 67TV IT _ wC, V,GP QEt-lC-S GGtzTlr T"AT TNT MU�bAj1o1� SNowt.l t4F-Zr- G Pt_VS W t7tA T►-I 51D .t_IN� •. �' w�� rAti.tt� 'SCTt;ACK 1 GQU19ZCM�uTS 01= T H� 'jo W 1J o;= �QRA5TA3 LG A.ut> 1 G QoT L•oGATEb• w l'T 1G•l l i i T wx-- I✓LOwb PLAI Q bA.TEz IZeral- tmar), 11• Wo 5ucvaY0e TI- 1-5 n��N 15 WOT Zascp 'V64 A" OSYE��/►Lt.E o M•�sS. I14 reviAGwr u9z%It,Y i rtAa-.- oF:e,crz. i4otjla ANpt_1 GAt�tT l Ul.CD TOt7eTccMlgC LOT -LiWa- VilL►L. EvE W-IT-r ') 66� L D L '► U,/1�L �V�IZ,iTT v DSP !e"`' l 1 / w � � 68 t y�•� o m i` ys•7 r,414 92• o G 9z.5 1 Atli,(off TaranF IgA A. w BAXTEn yl G'df i