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HomeMy WebLinkAbout0103 SANTUIT ROAD - Health 103 S-a^+•.•;t Road Cotuit A = 021 091 a i r COMMONWEALTH OF MASSACHUSETTS 3 EXECUTIVE OFFICE.OF ENVIRONMENTALAFFAIRS c DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION.FORM-NOT FOR VOLUNTARY.ASSESSMENTS. . SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: C,�C,II Owner's Name: / _ DEC 3 0 2002 Owner's Address: (/ TCiVvN OF BARNSTABL Date of Inspection.' Plot HEALTH pCpT E. Name of Inspecto plea a Sint) - Company Name. - `e` MAP Mailing Address: ) bOXCIle PARCEL . Telephone Number: /- LOT 31}. 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 performed 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; Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority. . Fails p.' Inspector's.Signature: Date:The system system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,00.0 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 approving authority. Notes and Comments % ouv- ****This report only describes conditions.at.the time of ins 4tion 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. Title'5 Inspection Form 6/1.5/20.00 page 1 S , Page 2 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE'DISPOSAL SYSTEM INSPECTION_FORM PART A CERTIFICATION (continued) Property Address: all Owner: Date of Inspectio%4iellwlyA,lccmoo Inspection Summary: Check A,B,C;D or E/ALWAYS complete.all of Section D A.• SS stem Passes: V I have not found an information which y h�ch indicates that any of the failure criteria described in 31 0 CMR ' ]5.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: `One or mor"e system components as described in the"Conditional Pass"section need to be replaced or repaired—The system, upon1completion of the replacement or repair; as approved by the Board of Health,vA.,ill pass. TO i Answer yes,no or not determined (Y,N,ND)in the for the following statements. If"not determined"please explain. 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 exfiltratiori 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: 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: 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: 2 Page 3 of 11 ' OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE.SEWAGE..DISPOSAL SYSTEM INSPECTION NORM PART A CERTIFICATION.(continued) Property Address:� . Owner: Date of l:ns ectio 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 C.MR 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 "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: 3 Page 4 of I 1 OFFICIAL:INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ` .PART A CERTIFICATION(continued) Property Address: t�' 0wnerl` - Date of lnspection i D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded-or clogged SAS or cesspool Static liquid level in the distribution box above outlet invertdue to an overloaded>or clogged SAS or cesspool _ Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface f water supply. _ Any portion of a cesspool or privy is within a Zone 1 of a.public well.U 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. [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 Jess than.5 ppm,provided that no other failure criteria �fl are triggered.A copy of the analysis must be attached to this form.] . (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 1%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 the system is within 400 feet of a.surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply 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. .4 t I Page 5 of 1 l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: w Date of Inspectio / a Check if the following have'been done:You must indicate"yes"or"no"as to each of the following: Yes No Pumping.information.was provided by the owner,occupant, or Board of Health _,,- Were.any of the system components pumped out in the previous two weeks? Has the system received normal flows in the previous two week period-Lzl ? Have large.volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined?(If they were not available.note as N/A) _ Was the facility or dwelling inspected for signs of sewage back up ? Was the site inspected for signs of breakout? Were all system components, excluding the SAS, located on site _ 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? 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 Existing information.For example, a plan.at the Board of Health. 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)] 5 Page 6 of I 1 OFFICIALINSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner. Date of Inspection o? FLOW CONDITIONS RESIDENTIAL X,` Number of bedrooms(design):_3 Number of bedrooms(actual): DESIGN flow based on 310. R 15.203(for example: 11:0 gpd x#of bedrooms): Number of current residents: n- Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system yes or no)• if yes separate inspection required] Laundry system inspected(yes or u° Seasonal use:(yes or n Water meter readings, if av ilable(last 2 years usage(gpd)): Sump pump(yes or i v Last date of occupancy: J/ AwRk; COMIVIERCIAL/INDUSTRIAkA '- Type of establishment: Desigri flow(based on 310 CMR I5.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):— Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system (yes or no):_ Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records. Source of information: , Was system pumped as.part of the inspe ion(yes or ): If yes,volume pumped: gallons--'How was quan ity pumped determined? Reason'for pumping: TYP F SYSTEM eptic 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/A Item ative 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): proximate a e of all c mponents, date installed ' known)and source of information: Were sewage odors detected when arriving at the site(yes or no): 6 Page 7 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM.INFORMATION(continued) Property Address: Owner. Date of Inspectio, BUILDING SEWER(locate on site plan),/)4h__ Depth below grade: Materials of construction:_cast iron _40 PVC_other(explain): _ Distance from private water supply well or suction line: Comments(on condition of joints,venting, evidence of leakage,etc.): SEPTIC TANK: locate on site plan) Depth below grade: 6 Material of construction: concrete_metal_fiberglass Polyethylene. —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: Sludge depth: Distance from top o .sludge to bottom of outlet tee,or baffle: I q Scum thickness: " Distance from top of scum to top of outlet tee or baffle: 7 Distance from bottom of scum to bottom of outlet tee or baf e: z e 9`V How were dimensions determined: Comments(on pumping recommen ations, inlet and outlet tee or baffle condition, structural integrity,liquid levels. s related to outlet inve ,evidence of I akage, c.); A 2ev GREASE TRAP (locate on site plan) �� t— C/ � Depth below grade:_ Material of construction:_concrete_metal_fiberglass-polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: &Ail" 1z Owner(.2(�q,- Date of Inspection ,, �Ua TIGHT or HOLDING TANKE,�(tank must be pumped at time of inspection)(locate on site plan) . Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions:' Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): , Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches, etc.): DISTRIBUTION BOX:Zif present must be opened)(locate on site plan) Depth of liquid level above outlet invert.t� ? � Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of age intq_o -out f box,et PUMP CHAMBfRjA- (locate on site plan) Pumps in working order(yes or no): Alarms in working order(.yes or no): Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): 8 Page 9 of 11 OFFICIAL.INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner. Date of Inspection. a SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) If SAS not located.explain why: Type eaching pits,number: leaching chambers,number: leaching galleries,number: leaching trenches, number, length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding, damp soil,condition of vegetation, CESSPOO -S�- (cesspool must be pumped as part of inspection)(locate on site plan) .Number and configuration: Depth'—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of.groundwater inflow(yes or no): Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.): PRIVY: locate on site plan) Materials of,construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM-INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection /(,P, C) 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. /7 J O 10 f _ Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C -SYSTEM INFORMATION(continued) Property Address: b Owner: Date of Inspection L 9' 000 a SITE EXAM Slope Surface water Check cellar Shallow wells Estimated.depth to ground water feet . Please indicate(check)_all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed:_ Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with.local excavators, installers-(attach documentation) Accessed USGS database-explain: You must.describe how you established the high ground water elevation: 11 Permit Number: Date: Completed by: HIGH GROUND-WATER LEVEL COMPUTATION Site Location:- / .3 Lot No. Owner: Address: SLR Contractor: . Address: '7 Notes: STEP 1 Measure depth to water table to nearest 1/10 ft. ............................... Date I`' Qz. I month/day/year STEP 2 Using.Water-Level Range Zone and Index Well Map locate site and determine: „ OAppropriate index well................................ .�. ...... �� © Water level range zone ..................................................... STEP. 3 Using monthly report "Current Water Resources Conditions" determine current depth to water level for index well ........................... month/year STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A), current depth to water level for index well (STEP 3), and water-level zone (STEP 2B) 3 determine water-level adjustment ...................... STEP .5 Estimate depth to high water by subtracting the water- level adjustment (STEP 4) from measured depth to water level at site (STEP 1) ................... 6 Figure 13.--Reproducible computation form. 15 v"t"y- , jj 7� .`cAAI��lCC. yy �•± 3) ` �!` C� .^ i LO CATION AGE PE RNIIT NO. `� ra VILLLAAGE �., I N S T A LLER'S A E i ADDRESS B U I L D E R OR OwlstR 't DATE PERMIT ISSUED DAT E COMPLIANCE ISS`U_ED � . G.S � IF d� �� �� �� mow,✓ �,��%� n No.....�. _... ? FEB.... a.w t'THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH v G�✓ O F.... 5'�7,� e:;;7............ Appliration for Uhipos al Works Tonotrnrtinn rranit Application is hereby made for a Permit to Construct ((_-�or Repair ( ) an Individual Sewage Disposal S tem at Location-Address ('^ or Lot No. ..��. -----------�Aty v..`.................... i� �—'�° ----•-•..........--- An owner Address Installer Address U Type of Building' Size Lot. ®V.e... Sq. feet ,_, Dwelling—No. of Bedrooms----------------------------------Expansion Attic ( ) Garage Grinder ( ) '4 Other—T e of Building No. of persons............................ Showers — Cafeteria Q' Other fixtures ...................................................... W Design Flow.........- 1.49.....................gallons per person per day. Total daily flow....... _42..................gallons. WSeptic Tank—Liquid capacity/M gallons Length................ Width................ Diameter---------------- Depth-.-_-__--__--___ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No....../----------- Diameter.................... Depth below inlet.................... Total leaching area.._..`_®...sq. ft. z Other Distribution box Dosing tank Percolation Test Results Performed bye, Date___ ...... Test Pit No. 1.....7,minutes per inch Depth of Test Pit...,l�------ Depth to ground water__A-' _ /_4— (T., Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water____-______-_-_----____. 9 ----•---•--•---•----•--------•------•••---....--•••---•----•---•--------------------•-••-•-••---••••........................................................ Description of Soil G �� �..� ... .._ t��� �Fzr. .---• x -•-- 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 TITLs±. 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee issue by the and o health. Signed. - ---------- -- ----- -- _-----••. •-••--•------------... ......... Date Application Approved By................ -------- ........_.... --- ..-- - Date Application Disapproved for the following reasons---------------------------------------------•----------•-------------------------------•----------..........••- ------•-•-•--------•.............•••--------•-----------...-•-----•-••-••---------------••......----------_....._........-----------------•---------------•-•--•--•--•-•----•----------------•---------. Date PermitNo......................................................... Issued...................................................... Date No._ v4 .• 4& Fizz..�P..�.�.............. y '_,--,THE'COMMONWEALTH OF MASSACHUSETTS BARD OF HEALTH oF...... 1{,! ; , !� ............. Allptirattiou for UiipnnFal Worko Tonstrurtiun 1hrutit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual kewage Disposal • "C- -Location-Address 1� .� 0 . 3�. ..... 1 . ........ or Lot No. p- ----- a v ..-�!- ...:-..... ............ .................... Owner Address w � .............C6_c:_ +t !x . ..... ............ -y.. . ....`......---.........------................ Installer Address PQ U Type of Building/ a Size Lot_ �? ..._Sq. feet Dwelling—No. of Bedrooms ,:_-. ---___-_--Expansion Attic ( ) Garbage Grinder ( ) A4 Other—Type of Building ................ .y.._...._ No. of persons............................ Showers ( ) — Cafeteria ( ) P4Other fixtures ---------------- ------ 1............................................................................................................................ W Design Flow.......... /_ems........................gallons per person per day. Total daily flow------:,...,5�.. _ ..................gallons. WSeptic Tank—Liquid capacrt/A!.24 _gallons Length................ Width................ Diameter---------------- Depth'.._--__---_---_.' , x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No....../------------ Diameter.................... Depth below-•inlet.................... Total leaching area..;?,6� ...sq. ft. Z Other Distribution box (t,-*)^" Dosing tank ( ) '-' Percolation Test Results Performed by 'rlmf`` .�-' !" ':_-1 ' Date... ....__. ,.a Test Pit No. 1.... -_-_minutes per inch Depth of Test Pit._1Z........ Depth to ground water_,h/20-tec�._.. Test Pit No. 2................minutes per inch Depth of Test. Pit.................... Depth to ground water------_................. ..................................--.............................. ......................... ......................................................... 0 Description of Soil...../,. -.__ .. ? �� E ...... _._ x V ----------------�'"`--".--,` •---' _..0 _-f, 4�c+''.e''! ---1:.�.'`_:. .:..+" --- ------'�/ ---a .�+�= = �------_--------_--- ----- ------ 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 TITIl"-15 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of'Compliance has.be issu d..... the health is � s Sgned. ------ ..... ...:.... ... ..__...... ..................•............. T Date Application Approved By-------------- �. Date Application Disapproved for the following reasons:................................................................................................................ .......................................................................................................................................................................................................... Date PermitNo..... ............................................. Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... errtif iratr of Tuntphau r THIS U TO C TIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by----------------- ......----------------•--•----•-•..._.........-------•----........----------------...`...-----------.-.........--•-------.......................•----•-- I tall at..................... y........... �--•------ . .-------- r'- -"'--•-------••-•--•----•------------ has been installed in accordance with the provisions of TITLES of kitate_Sanitary Code-as described.in_the. application for Disposal Works Construction Permit No......................................... dated-............................................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE;CONSTRUED AS A GUARANTEE THAT THE SYSTEM Wl F CTION SATISFACTORY. DATE.... . . •................>------......-- =;---------- Inspector, ----- --------•------...--•--...-------------------------•-••---------....4.. i THE COMMONWEALTH OF MASSACHUSETTS BOARD OF, HEALTH tO F.................................................................... (� N .-.�'.` _. ..... FEE-"-•................... �i��.���t1 lurk �un��rimrn rrnti� Permission is hereby granted............. -i2_ ..:._ `..-------••--•----------•-----•------------------------•-•.......---------......................... to Construct ( ) or:Repair ( ) an Individual Sewage Disposal System Street as shown on/theapicatio or Disposal Works Construction Permit No..................... Dated..__._._____.............................. ---------------------------------------------------------------�/ Board of Health DATE0 s FORK 1255 A. M. SULKIN, INC.. BOSTON �� -_ St.iGLG- FAMtL`C •- �5 BeoROoM —�P. z, 3 o �. WO "GAczt3AG6 (�LZtNDE2 ,� lzy".00 �° �cn : ,.p. 'I SEPTt� TAbJK = 330x15C>.'/• A9/F6.P. P. I tustC t000 SAL. _ o►SPoSAL_ Prr v5lCY t000 GAL. GOB G70 S�ncrra�L A.eEa. _ ►5�s.F �.�� . t5a 5.� X 2.5 = 3?5 G.Po p� Ae&A 130TTOA AREA= , j0 S.F,_ Q r ) 9P•o boa Q j So•5:� x 1•o 5'o G•P c . . . oCA I 'TaTAL- U;ptaSIGN a 425 (�•R D. g v - dl-WT . A t i-�( F moo ..= 3 3 o G,P D, rR°, J 1! P zc-oLA.-rioN RATE: 1''rN 2MIN OP-La55 91 � Dw�!_t.l IJ c I 3 !i a4 OF lt J jl t BAX I CN V u t No 29976 40 C/STEP{�Q• • S T U �?—o A z�) j j E �T (7 4•S3 fG r 9G To P FND= 97 ✓rl�45 ��� '' iNV. loov INS• 'S�9fiO1C DtST. INS GQt.. ? SEP71G 'p ,� 1000 INV• gux 9'�,L TANK GAS. 93 LEacu F I P1T INV. INV. CoTv� wI-rN 93.2 9�•¢ - AA 1 SA t1D WASNG D 6TvNG GER.TtFta PLoT P"A►1 uo SCALE SCALa I'I='44J VATS S /2�18� I • �p�OS b t� p L.p N REF:E 2E rat GE I �. - ► cEcrtiF-Y TNAT THE Uwe-LING 5uown! e.. -- 3� ��tcot� GOMP�-�{S YJITN-C HE �,1 D�LIN I T„ f�uD SEzt .GK R.6QtJ►i2 MENT> o 1C 4 Lo -.o w N o� -fi A T�+3�A rA-D ►s NET" t-t�Gp.T D 'W THi T , G L.o D Py. 1 N 'Z 1 BA-ATav- ► l`{E INC• R.EG 1 SZ 626'D'►..AW o'S u 7-v eYoes _ 1lIS PL&1J P5 Nei (3n5c p o►d AW C>STE2.VILLF • MASS• 1 1w,57-9_uMaNT 5uevey � -t'NE oF=F,6ET5 SUouL, i No-r t3E u56DTo 0E7tkR:: 1N4 .t_ot �_ I1-lE5 APPLICA►--lT �� , �/ - - U — I)I[l A I (�ti - - -- -