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HomeMy WebLinkAbout0065 TRACEY ROAD - Health 65 TRACEY ROAD, COTUIT A= 005 O61 i 1 TOWN OFB STABLE ..LAdE �O `" ASSESSOR'�OMAE LOIV, T, STALLER'S NAME&PHONE NO. /✓ ' y" ���`�� SEPTIC TANK CAPACITY; f3� �ysgg LEACHING FACILITY: (type) IT (size) NO. OF BEDROOMS"' BUILDER OR OWNER P� Y ��r y r ""r. t PERMITDATE: '' v COMPLIANCE DATE: - � t 'Separation Distance Between the: ' 5. 41'Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility,r- Feet Private WaterSdpliry Welland Leaching Facility (If any wells exist t on site or within 200 feet of leaching facility) Feet Edge'of Weddrid-and Leaching Facility(If any wetlands exisi- within 30Q,feet of leaching facility) - Feet Furnished by f r . No. 7d0!�-a 7 33 . Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:./ Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE,, MASSACHUSETTS 01ppYication for Migoat *p5tem Contruction Permit Application for a Permit to Construct( . )Repair( Upgrade( )Abandon( ) El Complete System X Individual Components Location Address or Lot No. Owner's N e, ddress and T 1.Np. Assessor's Map/Parcel o - 06/ Lrlt�t Install 's Name Ad ress,and Tel.No. Designer's Name,Address and Tel.No. of f- clo l S"_' 0 Type of Building: Dwelling No.of Bedrooms Lot Size a s V ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 1330 gallons per day. Calculated daily flow gallons. 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: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by t 's Board of Health. Signed Date Application Approved by Date Application Disapproved for t e following reasons Permit No. 20 ds——q 5 3 Date Issued a No. ao 3' Fee THE COMMONWEALTH OF MASSACHUSETTS Entered.in computer: { Yes cPUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS Appriration for Migpool 6pdem Coug'tr-u.ctio-h-•Permit .F Application fora Permit to Construct( , )Repair(V,,)Upgrade( )Abandoii( ) -O Complete System 'X Individual Components Location Address or Lot No. .5 I Owner's Name, �Address }and T� / Assessor's Map/Parcel (4 �< ��� r' v - 06 Install is Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling- No.of Bedrooms _ Lot Size ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. ' Plan Date Number of sheets Revision Date =� Title Size of Septic Tank ' Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 1A 01/4 7 .1 Ylf /Q 4 Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health. Signed Date ct Application Approved by Date -"Application Disapproved for t e following reasons Permit No. -?IWC— Y�3 Date Issued o THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Com riance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired ( ()Upgraded( ) Abandoned( )by TZ4J at has been construct d n accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 2 06,r_�33 dated I us- Installer Designer The issuance of this pe it shall not be construed as a guarantee that the system ill unctio as designed. h Date a) Inspector I h • r 1 J, No. / d Fee �V � THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS migo!gai 6pgtem Con.5truction Permit Permission is hereby granted to Construct( ))Repair(VI Upgrade f ) bandon( ) System located at � _Y /� '�i �l �Y� �Ty 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:Cons ctio must be completed within three years of the date of t s i . Date:_. / ' Approved by �L✓' REPOS SEPTIC TION SETANK N 20032'00"E ORIGINAL 180 00' LEACHING PIT LEACHING PIT INSTALLED 1997 `� , o , 000 PROPOSED 1 0 , . ,---- ADDITION s HOUSE NO.65 o Q LOT 19 z 20 025 SE. 14.90' 22.00' 00 0 o EXISTING DWELLING N �, 09 cn o 22.03' 20.00' 23.21' 56.1' 1 a y 180.00, S 20032'00"W TRACEYROAD .. REVD.MAY 18,2005 ADDITION "I certify that the dwelling shown on PLOT PLAN OF LAND this plan is as it actually exists on the LOCATED IN • ground i orms to the town of Ba dr gkeV onsregarding COTUIT,MASS. y �i: �, PREPARED FOR R.L.S. GERALD GANEY • �"` — �'�'�•�_`�� rt3U"t{� oos DATE:MAR.3,2005 SCALE: 1 "=30' floo ~c 'kh CAPE 8i ISLANDS ENGINEERING trac �kta;l=`� � MASHPEE,MASS. i - t Commonwealth of Massachusetts Executive Office of Environmental Affairs Dept. of Environmental Protection One winter Street, Boston,Ma. 02108 •tol Usti D.E.P. Title e V Septic htspector P.O.' Box 2119 Teaticket,MA 02536 WILLIAM F.WELD (SOS1 0 I3 Governor49 ARGEO PAUL CELLUCCI Lt.Governor ip ©OS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ORT A tS (p CERTIFICATION l t.+ !f9Property Address: 65 T� S rr Date of Inspection:912197 acey Rd.Cotuit Af diffe dress rent) of caner: 'y��ti��p�lgB`� Name of Inspector:John Grad Mrs.Burton:Box 1445 Cotuit Ma.02635 N I am a DEP approved system inspector pursuant to Section 15.340 of Title%.(310 CMR 15.000) Company Name,Address and Telephone Number: t i CERTIFICATION STATEMENT i 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: P X Passes This inspection is based on criteria defined in Title V Conditionally P Ss es code 310 CMR 15.303.My findinqs are of how the system is Needs F h Evaluation B the Local Approving Authority performinq at the time of the inspection.My inspection does Y PP 9 b not imply any warranty or quarantee of the IongeviN of the Falls septic system and any of its components useful life. Inspector's Signature: Date: 913197 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. 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.{ i INSPECTION SUMMARY: Check A, B,C, or D: ! j A] SYSTEM PASSES: X I have not found any information which indicates that the system violates any of the failure criteria 1 defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes,no,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, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal, is cracked,structurally unsound,shows substantial infiltration or exfiilratiori,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04/27/97) i One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 9 Telephone(617)2925500 i { SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) i I i Property Address: 65 Tracey Rd.Cotuit i Owner: Mrs.Burton:Box 1445 Cotuit Me.02635 I Date of Inspection:9r2/97 { — Sewaae backup or.breakout.or. hiah.static water level observed.in.the distribution box is due to a broken. 1 or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if (with approval of the Board of Health). Describe observations: i broken pipe(s)are replaced f obstruction is removed distribution box is leveled 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): t. i 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 (t system is failing to protect the public health, safety and the environment. f 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS f 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 I Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. t t 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER, IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTIONING 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 of water supply or tributary to a surface water supply. I — The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply 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 the SAS 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 that facility and the presense of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid) j 3)Other t • f D] SYSTEM FAILS: I You must Indicate either"Yes"or"No"as to each of the following: 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 should be j contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage in facility or system component due to an overloaded or clogged SAS or cesspool. 1 . Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged cesspool. I{ SAS is in hydraulic failure. t i (revised 04Q7/97) I 1 I { ' I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM j PART A f CERTIFICATION(continued) Property Address: 65 Tracey Rd.Cotuit Owner: Mrs.Burton:Box 1445 Cotuit Ma.02635 t Date of Inspection:9/M7 D] SYSTEM FAILS(continued) i Yes No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged 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). Numbers of times pumped I 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 1 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. k { i E] LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: The following criteria apply to large systems in addition to the criteria: I The system serves a facility with a design flow of 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: r Yes No l 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) f 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. r 1 I t A l f I (revised 04127/97) • i Itt i F SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST i Property Address: 65 Tracey Rd.Cotuit t Owner: Mrs.Burton:Box 1445 Cotuit Ma.02635 f t Date of Inspection:9/2/97 ; Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: _X_ — Pumping information was requested of the owner,occupant, and Board of Health. ] f x — None of the system components have been pumped for at least two weeks and the 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. x As built plans have been obtained and examined. Note if they are not available with NIA. i x — The facility or dwelling was inspected for signs of sewage back-up. { x — The system does not receive non-sanitary or industrial waste flow. -.X— — The site was inspected for signs of breakout. x — All system components,excluding the Soil Absorption System,have been located on the site. x The septic tank manholes were uncovered,opened, and the Interior of the septic tank was Inspected t] for condition of baffles or tees,material of construction,dimensions,depth of liquid, depth of sludge, depth of scum. i x — The size and location of the Soil Absorption System on the site has been determined based on The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal Systens. x Existing information. Ex. Plan at B.O.H. x Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is unacceptable)]15.302(3)(b)] i t 1 i 1 i ] 1 t i 1 i t (revised 04/27/97) 1 ) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION i t t - t Property Address: 65 Tracey Rd.Cotuit ' Owner: Mrs.Burton:Box 1445 Cotuit Ma.02635 (_ Date of Inspection:grM7 fff 4 FLOW CONDITIONS RESIDENTIAL: Design flow: 440 g•p•d./bedroom for S.A.S. i Number of bedrooms: 4 Number of current residents: o I Garbage grinder(yes or no): No I Laundry connected to system(yes or no): Yes Seasonal use(yes or no): No Water meter readings,if available:(last two(2)year usage(gpd): ' n/a j Sump Pump(yes or no): No Last date of occupancy: 1 yearago COMMERCIAL/INDUSTRIAL: Type of establishment: n/a Design flow:0 gallons/day Grease trap present:(yes or no) No t Industrial Waste Holding Tank present: (yes or no) No { Non-sanitary waste discharged to the Title 5 system:(yes or no) No t Water meter readings,if available: n/a Last date of occupancy: n/a OTHER:(Describe) n/a Last date of occupancy: 1 GENERAL INFORMATION PUMPING RECORDS and source of information: System was last pumped two years ago. System pumped as part of inspection: (yes or no)No $, If yes,volume pumped: 0 gallons Reason for pumping: n/a i TYPE OF SYSTEM { X Septic tank/distribution box/soil absorptions system p Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes, attach previous inspection records,if any) j - .UA Technology etc. Copy of up to date contract? Other: r i APPROXIMATE AGE of all components,date installed(if known)and source information: I Tank 1983 with upgrade 1989 _- _ Sewage odors detected when arriving at the site: (yes or no) No t I (revised 04/27/97) t i I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) I 1 Property Address: 65 Tracey Rd.Cotuit Owner: Mrs.Burton:Box 1445 Cotuit Mo.02635 Date of Inspection:9fM7 SEPTIC TANK: X (locate on site plan) Depth below grade: 1' Material of construction:X concreate metal_FRP_Polyethylene_other(explain) If tank is metal, list age o . is age confirmed by Certificate of Compliance No (Yes/No) Dimensions: L 8'6'H 5'7'W 4'10' Sludge depth:1" Distance from top of sludge to bottom of outlet tee or baffle: 26" Scum thickness:0 Distance from top of scum to top of outlet tee or baffle:2' Distance form bottom of scum to bottom of outlet tee or baffle: 0 How dimensions were determined: Measured Ef 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.) Septic tank and all components are structurally sound.Recommend pumping septic system every two years for maintenance. f t GREASE TRAP:_ f (locate on site plan) i Depth belowgrade: n/a Material of construction: concrete metal FRP Polyethylene_other(explain) Dimensions: n/a Scum thickness:n/a Distance from top of scum to top of outlet tee or baffle:nfa Distance from bottom of scum to bottom of outlet tee or baffle: n/a 1 Date of last pumping,va 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.) n/a i BUILDING SEWER: (Locate on site plan) i Depth below grade: r'6' Material of construction:_cast iron X 40 PVC_other(explain) t Distance from private water supply well orsuction line?own 1 Diameter: 4'_ l C,vamments:(conditions of joints,venting, evidence of leakage,etc.) E revised 04/27/97 i i t f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 65 Tracey Rd.Cotuit Owner: Mrs.Burton:Box 1445 Cotuit Me.02635 Date of Inspection:9/97 {; 1 • t TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_FRP_Polyethylene_other(explain) r Dimensions: n/a Capacity: n/a gallons Design flow: n/a gallons/day i Alarm level:—n/a Alarm in working order?_Yes_No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches, etc.) n/a ' I DISTRIBUTION BOX: t (locate on site plan) 1 Depth of liquid level above outlet invert: n/a i Comments: 1 (note if level and distribution is equal,evidence of solids carryover, evidence of leakage into or out of box etc.) We I f l PUMP CHAMBER: i (locate on site plan) Pumps in working order:(yes or no)No Alarms in working order(yes or no)_Yes t Comments: (note condition of pump chamber,condition of pumps and appurtenances, etc.) n/a i j# 1 ( i 1 i i 4 i (revised 0427/97) i 1 I 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM I PART C SYSTEM INFORMATION(continued) Property Address: 65 Tracey Rd.Cotuit Owner: Mrs.Burton:Box 1445 Cotuit Ma.02635 Date of Inspection:9r97 I SOIL ABSORPTION SYSTEM (SAS):X i (locate on site plan,if possible; excavation not required, but may be approximated by non-intrusive methods) i t If not determined to be present, explain: ) We P Type: 1 leaching pits. number: 1,oao gallon leach pit P leaching chambers,number:n/a F leaching galleries, number: n/a i leaching trenches,number, length: We leaching fields, number, dimensions:n/a overflow cesspool,number:n/a Alternate system: n/a Name of Technology:_n/a Comments:(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.) i The leach pit is structurally sound and functioning properly.It was empty at the time of the inspection.Pit has not had more than 1'of water in it. I d I CESSPOOLS:_ (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: n/a inflow(cesspool must be pumped as part of inspection) n/a t ) f Comments:(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) n/a j i PRIVY:_ (locate on site plan) Materials of construction: n/a Dimensions`. n/a f Depth of solids: n/a Comments:(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) t n/a i ` t . i _ I i (revised 04/27/97) I } ( SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) { 65 Tracey Rd.Cotuit Mrs.Burton:Box 1445 Cotuit Me.02635 9/2/97 ) SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references, landmarks or benchmarks• locate all wells within 100'(Locate where public water supply comes into house) } I l 1 t yI} f AA AC �y y , I (revised 04/27/97) page f of 10 } t { { f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C r SYSTEM INFORMATION(continued) 65 Tracey Rd.Cotuit Mrs.Burton:Box 1445 Cotuit Ma.02635 9/M7 i Depth of groundwater 12+ j Please indicate all the methods used to determine High Groundwater Elevation: ! l Obtained from design plans on record. Observation of Site(Abutting property, observation hole, basement sump etc.) r l Determine it from local conditions Check with local Board of Health Check FEMA Maps Check pumping records Check local excavators,,installers k x Use USGS Data t r Describe in your own words how you established the High Groundwater Elevation.(MUST be completed) USGS Maps and Charts G 4 i l i. i i[f l i t i IE] 1 . k yyrk k I }{t . 1 (revised 04J27f97) page 10 of 10 ! TOWN OF BARNSTABLE LOCATION `79?C SEWAGE # 41— ASSESSOR'S MAP Cz LOT oil 1 ram' INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY /"V' f A-I LEACHING FACILITY:(type) �°' /�''°"��' / (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER P l e4 DATE PERMIT ISSUED: 10, DATE COMPLIANCE ISSUED: o6 7 VARIANCE GRANTED: Yes No c/ i �• p �k 11 THE COMMONWEALTH OF MASSACHUSETTS OAR® OF HEALTH O` ........oF... . ........................................... Appliration for Disposal orkg- Tonstrurtiun Frrmit Application is hereby made for a Permit to. Construct ( ) or Repair 4_l an Individual Sewage Disposal System at: ._.......... .......................... o Location-Add, ss ] or Lot No. ........C.O. u! . ......................... fQ�s, :.._...._.•.... .....1....._-.---------------ozkcLa .....- Owner Address ----�+-'•------•--'�+ ��.f: .................................................... .........._...................................................................................... Installer Address Type of Building Size Lot............................Sq. feet U q Dwelling—No. of Bedrooms---------- __________________________Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building .... No. of persons............................ Showers — Cafeteria a'' Other fixtures _______________________________ _ _ W Design Flow........ 5b................gallons per person per day. Total daily flow......_ .___...______.__.___,.__ ..gallons. 1:4 Septic Tank—Liquid capacity.)V _gallons Length................ Width---------------- Diameter---------------- Depth................ Disposal Trench—No. _....(9NNvth... �} ---------- 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 by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water......................... Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ --------------------------------------------------------------------------------•---....----------•-......................................................... Descriptionof Soil........................................................................................................................................................................ x W -•-••-••--••-•--••---------••---•-•-----•-•----•---•-•-••••----------•-•-•-••--•••-••••......•-••-•--•••-•-----•• . --• ----------•_.._. ----------- -------------- ------------ UNature of Repairs or Alterations—Answer when applicable---------- `._C �? d�__ __------- _ 1 .................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iTT y g p y of the State Sanitary Code—The un er tied further agrees not to. lace the system m operation until a Certificate of Compliance has be ed by rd of health. Signed . .............. � Application Approved BY� .••-- --------- ............ ate D Zat e D Application Disapproved for the following reasons----------------•--------------------•------------------------------------------•-------------------------•--•-- ......................................•...•-•••--•--••••-•-••••--••.................••••-•-••••••-•--••--•-••-•••••••••••-••-•-•••-•••••-•••............---------------------------------•------------ at /97 -- -•-••• e Permit No........... -- --••.... Issued-----.....•... v� 2� No.. ..............� FEs ....��:........ THE COMMONWEALTH OF MASSACHUSETTS ., CARD OF HEALTH Appliration for Elisposal aark9 Tonitrurtion rumit Application is hereby made for a Permit to Construct ( ) or Repair 4- J an Individual Sewage Disposal System at: ...A.�-.1-.2.. �.O' ..1���� . ------------- ---•- ••---------.......------. - ............................................... L -- -- - Location•Add ss �• � - ..� � or Lot-No. cDyl... ......-•---....-•------•--..��lV.f�------------------ ..-•................ _. ......... .......... -- '•'J�/�}/^/ Owner Address •__.SJ _._..brc� V> }�.�.�r..........................•___-..._................ ........_•_.___....____.._..._.--................................................................. Installer Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms..............T ..........................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building No. of persons............................ Showers — Cafeteria a YP g P ( ) ( ) Q' Other fixtures .................................. ------------------•.------••-••-••-••---• ............... -------------•----•------ W Design Flow....... .................gallons per person per day. Total daily flow..... .__gallons. 9 Septic Tank—Liquid capacity t t_'`____gallons . Length................ Width................ Diameter................ Depth................ Disposal Trench—\To.--':;a..... ............ 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 by.......................................................................... Date........................................ aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground eater_--__-_.--___-______---- (T., Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 -----------••-•--•------------•-------------•-•............................................................................................................. 0 Description of Soil........................................................................................................................................................................ x V .._..-•-------•---•--------------•------•--••---•---.....---•-------------------------------------•...........-----------._...--••---•--•-----•---------•---•-------•---------------•--------•-----..---- W -----------•----------------------------•-----••-•---------------------------.....-----•----•-•----•--------------A-----•------•••-••••-•---------------------.._..t-•----•---•----------•------_..._. UNature of Repairs or Alterations—Answer when applicable________ ______.._...?^ .:...'...."...`.____.__ __ .�_l_....? ......_.......•...... -----•---•-••••--•---•--•----•----•--------•••---•-•--•-------------------•--...........----•-•---------•--••-•--•---••••------•••-•-----•••---------------•-•-•-•-•----•---------•-•---.....••-• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of i-t ice: 'of the State Sanitary Code—The un'er •gned further agrees not to place the system in operation until a Certificate of Compliance has bg issued by� and of health. Signed (` .. ....................................................... � 7 ate, A lication A roved B 5­_ )_�.._ l ...... ............ j -�- i�.- �-- ----- ----- - Date Application Disapproved for the following reasons:.............................................................................................................. .............•-••......----------•---------��•.._...r'.... ...-----------......_..............•---•-----------------------•-•-----•--•--------; --.......-----......----------....._------ r-••—� -� Date )�� 1 Permit No. �-- ........................... Issued............. ---------------- Dace ! r THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Trrtif iratr of Tuutpliattrr THIS aTO�RTIFK Th the Individual Sewage Disposal System constructed ( ) or Repaired by..----f-..........s_. -- at.....'T""-_-U= �G l� ......... �' � In�ealley J � ~1� has been installed in accordance with the provisions of Ti TIE__ 5 of The State Sanitary Cod.7as descr'�d.�in the application for Disposal Works Construction Permit `o._I�•._I-- !�s_��°_...... dated..........:...�..`_`�_. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE SYSTEM WILL FUNCTION SATISFACTORY. DATE......................................................................•---...... Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...............?...- .... ............ J CU �(11 w NcP....................... FEE........................ Dispo al ork.5 Tonstrurtion rrutit Permissionis hereby granted.............................................................................................................................................. to Construc t ) .or Repair ( a Individgal,Sewage Disposal System Gt. T �/�Ai cC G Q u.. '.......................�.. ................... ............................. 1-------------------- street �;- - / as shown on the application for Disposal Works Construction Permit NoS _. _.L'.`'_ Dated.._ ---- ..� ........ ........... s. .^. �» .rry y.0 /�� /w�� _ .............................. s Board of Health DATE ='` �P FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS ``* f F Lt+ CAT 0N SEWACE PERMIT N0• VILI_ ACE Cta 7'-V i I H S T A LL.EIt NAME i ADDItESS IEUIL0ER OR OWNER _ dio s DA T E P ER041T ISSU E,D DATE COMPLIANCE ISSUED '\ . � �� '� 0 .- i II� { � � � I ,� 1� ! + � � '', �, 1� '' � �; � ' -- .. �: .............. : THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH y ............:.... ...................O F.......................................................................................... Allp iration for Disposal 10orkii TonAtrurtion famit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: .......40.� .....� �-------- .... . ...-•....................... .........:............ ....-- - ®,� Location- ddress or Lot No. 141� Owner Address Install Address d Type of Building Size Lot.............--------------- Sq.. %u Dwelling—No. of Bedrooms-----`I.............-...................Expansion Attic ( ) Garbage Grinde '4 Other—T e of Building No. of persons............................ Showers — Cafeteria dOther fixtures ------•--------•----------•---------------------------••••••---••--•••••--•--•......•-- -------•--••-••••--•••-•--••••....0.............--•----•-•-•- W Design Flow........a.�9..............•........gallons per person per day. Total daily flow....... ,,JP�__._............--...•..gallons. WSeptic Tank—Liquid capacit.010._gallons Length---------------- Width................ Diameter---------------- Depth................ x Disposal Trench—No..................... 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 ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ••••--•••••-•......-•••-••-•-----••-•••--••••••-••-••••----••----•..................•--•-----.............................................................. xDescription of Soil............................................-........................................................................................................................... U •••---••--•--•••-•••••••••••••••••••-••----•••--••--••-••......•.............•••-••••--•--•••--------.....-----------•••------•---••-•-•-•----.......••••••......--••----•..------•--•-••............. W x C/6y.�iGK« ro - /u s r�u �-�ctr�.� Ur Nature of Repairs or Alterations—Answer when applicable--------- --__---..._.....__......____.._..._.___..._...................... ...... /,¢.?•- �`D`7 G�Gurcne _ ` U T-•-•-•... ...............--- jj :�r ----6J------....6f1 C,............................ � .L � - Q Agreement: 7- 8� The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITLL 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certitigce has been issu by the boar f he th. Application Approve ----------------------------------------•---••• •----- Application Di pprng reasons:-------•......................••••-----••-•-••••......•-- ---------------------------- y ate" ___________________________________________________________________ last` i Date " PermitNo..................................= ------------ Issued..--...................... t Date No... z.�.�.� .1. F�s...�j.._............._ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...............................--..........OF..........................._...........------------...................................... lirativif for Diipuual Workii Tomitratrtiun amit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ......., . .1 .. .7• �.... ...1 .......................... ---------------------............-----_----------....----••--------.__--_•_-_•-....-.....-_••---- ocatio -Address or Lot No. ........ . ?t : ? ......--•-------------------------------------- . .:�,�:.. �.....-•9, -r cum ...... . Owner Address Installe Address d Type of Building Size Lot............................Sq. U Dwelling—No. of Bedrooms...._.................................Expansion Attic ( ) Garbage. Grinder 1.4 Other—T e of Building ........... No. of persons............................ Showers — Cafeteria a YP g P ( ) ( ) 04 Other fixtures ----------------•-------•-----------•--•--------•----•••---•--•-•-••--•••-•-•-••••-•••--••-•••-•----•-•-•-•--•-•••-•--••-•-•--. W Design Flow.._...._.a.B.P......................gallons per person per day. Total daily flow__......,'p.._....................gallons. 04 W Disposal Trench i u�doca acit ••��-Widthns Length Total Lengthidth--.----.:.-:._-ToDtal leaching area_- Depth................ Septicq P Y� g g x ....................sq. ft. Seepage Pit No.............yq __.. Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Other Distribution boxes( ) Dosing tank ( ) Percolation Test Results `Performed by.......................................................................... Date........................................ aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water......................... fi Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 04 -----------------------------------------------••-•---••--•----_--.......................-----..__......-___---------_____-.•-__----••---------------------- 0 Description of Soil................................................................•---••-•-••__•••••.•... ....................S.. ..••-•-•••••••••••-••-•••••--•••••••••..............••... x -------------------:.....----------------------------------------------..................I..•----"••------------------------------•---•••••••-•••••--•--••••••-......•••••._...••------•- U Nature of Repairs or Alterations—Answer when applicable......___________________--------- -.......-------------------------- _._................ ....... C't uc te, LG !"'' L / c.� ................................................-•............................................•- .................... •.......::, ................ Agreement: !�'C d�rdr u tc. _ l l• <?. - �14e The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT1E 5 of the State Sanitary Code— The undersigned further agrees not to place the system in opera ion until a Certificate of ompliance has been issu by the board of h t—AAAi e'th.Sign f . > to "' ." � Application°-APProved..-$Y----`'�`----�-�----- .................................................... - . tF Date Application Disappro for t e f ollowang reasons .......................................----------------------------------------------------- ................•••••--•-••-•---•- -----••. •-•-•-•• -••-•--- ......•. -•-•••-••-•-----••••••••--•----•-•••---•••------------•--------••-----••---•••......-•--------- Date PermitNo.............................. Issued :::....-----•_-_........................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARDF �tHE L ;.............OF...... ..... . ..::F..::.. .......................................... (InrtifirFajtr of TompliFanrr TES IS TO MTIjU Tat the Indi idual wage isposal S stem constructed ( or Repaired ( ) y I ,�; Installer at-•-•-• R P.. _ rf. ................................................................................... ------- -••---•---•-•---••-••- .r has been installed in accor with the provisions of TI2W ` f The State Sadnta�Iry Cody as �ibed in the 4� •4N� a lica.tlon for Dis osal or Construction Permit No._____ _"_. _. ----------------------- THE ISSUANCE THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.............................................. � InsPector--------- � ----------------------------------- -��THE COMMONWEALTH OF MASSACHUSETTS r BOA.TCW—HEA - No.. .....7 ... FEE.. ................ ill o u ku aan'u ' n rrntit Permission is ereby grante _,� . ----- .-- --•~.. ....-- ---�-'------f. .------.. � ....................... to Constru or Re )®an In. ivi al Sewage Disposal System atNo... t._........ ------- - ... .................................................................................... Street as shown on the application for posal Works Construction Permit No._. ' _M __.-�`'� ated. __` _ Of...................... �%,..' ............................................i DATE................................................................................ //oard of Health FORM 1255 HOSES & WARREN. INC., PUBLISHERS NOT TO TOFA Al EL' `�/ Sl3 FiN/SN G.PApE O YER ''i•, i V FyN/SN �R•�70E OVE� O/S T. 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