HomeMy WebLinkAbout0031 WHITE'S LANE - Health (2) LA
Whites Lane, Cotuit 027.003
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.COMMON,NVEALTH OF MASSACHLSETTS
y EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTIO\
ONE WINTER STREET. BOSTON. hI.4 02108 61 7-291.5500 '
WILLIA\+F.WELD TRUDY CORE
Governo: Secrew
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner
PART A
CERTIFICATIIONOo 2
Property Address: 3/ W4. t s 4Hh.e �v , t �Z/ Address of Owner:
Date of Inspection: /2' :2 _4B (If different)
Name of Inspector: 1911" rgalf
I am a DER approved ys em_i,�speyyt99r pursylant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: t7d�+H �� 9c Kho C jeraGC e
Mailing Address: /Sp !'f pit Z, S .,
Telephone Number:
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 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:
Passes
_ Conditionally Passes
_ !Needs Further Evaluation By the Local Approving Authority i
Fai s U
Inspector's Signature: C/ 22y— Date:
The System Inspector all submit a copy of this inspection report to the Approving Authority within thirty (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 SUMMARY: Check A, B, C, or D:
AI SYSTEM PASSES:
�I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below..
COMMENTS:
BI SYSTEM CONDITIONALLY PASSES:
One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon
completion of the replacement or repair, as approved by the Board of,Health, will pass.
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 exfiltration, 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 04/25/97) Page 1 of 10
DEP on the World Wide Web: http://www.magnet.state.ma.us/dep
i
- _- Printed on Recvcled Pacer
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
. PART A
CERTIFICATION (continued)
Property Address: 3/ 1,aHt C1-111-r f /Q
Owner: f
�uSSP�� *- �k�i1//H
Date of Inspection: gg
B) SYSTEM CONDITIONALLY PASSES (continued)
Sewage backup 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). Describe observations:
broken pipe(s) are 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 FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system (SAS) and the SAS 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 the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS 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 presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method used to determine distance (approximation:not valid).
3) OTHER
(revised 04/25/97) Page 2 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: lei 40"e
y/
Owner: /Qu ss l
Date of Inspection/�,
D] SYSTEM FAILS:
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 contacted to determine what will be neces y to correct
the failure.
Yes No
Backup of sewage into facility or system component due to an 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 6wed SAS or
cesspool.
Static liquid level.in the'distribution box above outlet invert due to an overloaded or clogged SAS or cessWol.
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
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
_ Any ponion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface waster 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 waxer analysis for
coliiorm bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
EJ 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 above:
The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significara threat to
public health and safety and the environment because one or more of the following conditions exist:
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 ll 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.
(rovissd 04/25/97) Pago 3 of 10
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 14h2 Cols. �111
Owner: /r�fl-e 'f 71 d ` r�lii.le
Date of Inspection:
i�- 2
Check if the following have been done: You must indicate either "Yes"or"No" as to each of the following:
Yes No
Pumping information was provided by the owner, occupant, or Board of Health.
None of the system components have been pumped for at least 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.
_ As built plans have been obtained and examined. Note if they are not available with N/A.
t/ _ The facility or dwelling was inspected for signs of sewage back-up.
Z _ The system does not receive non-sanitary or industrial waste flow.
_ The site was inspected for signs of breakout.
All system components. exchni -ri the Soil Absorption System, have been located on the site.
The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of
baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
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 System.
_ Existing information. Ex. Plan at B.O.H.
_ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) (15.302(3)(b))
(revised 04/25/97) Page 4 of 10
` � t
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
Owner: �?vss.l / `o' rap�r"iL. u/4'f-!
Date of Inspection: ¢
FLOW CONDITIONS
RESIDENTIAL:
Design flow: -;:76' p.d./bedroom for S.A.S.
Number of bedrooms:3
Number of current residents:
Garbage gri:.der (yes or no): 1A/c
Laundry co-I netted to system (yes or no):. s
Seasonal use tyes or no):�u �
Water meter readings, if available (last two (2) year usage (gpd): °'� g7 iv Ucf Qg 30 QvO yal,
Sump Pump lees or no):�
Last date of occupancy: VCe "tea n raw
COMMERCI.AUINDUSTRIAL•
Type of establishment: ,
Design flow-: gallons/day
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:
OTHER: ;Describe!'
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information: n "'
System pumped as part of inspection: es or no)_
If yes, volume pumped: gallons
Reason for pumping
TYPE O,F SYSTEM
Septic tank/die soiI absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
I/A Technology etc. Copy of up to date contract?
Other
y ,
APPROXIMATE AGE of all components, date installed (if known) and source of information:
Sewage odors detected when arriving at the sitei'(yes,or no)
(revised 04/25/97) Page 5 of 10
{
E
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: / !/
Owner: jcise l ¢ 7.,4A ",It
Date of Inspection:
/2- 1
BUILDING SEWER:
4Locate on site plan)
Depth below grade:_:r�
Material of construction: cast iron 40 PVC _other (explain)
Distance from private water supply well or suction lir•4-
Diameter
Comments: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK:_
(locate on site plan)
Depth below grade:
Material of construction: concre _metal _Fiberglass _Polyethylene _other(explain)
If tank is metal, list age_ Is age confirmed by Certificate of Compliance _(Yes/No)
Dimensions: g $
Sludge depth: /1"
Distance from top of sludge to bottom of outlet tee or baffle: /e!n
Scum thickness: oy
Distance from top of scum to top of outlet tee or baffler
Distance from bonom of scum to bonom of outlet tee or baffle: / ,•
How dimensions were determined: NlegiPrlyy J14" 4 RH/rr
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 le kage, etc.)
idrr 4 i v� t c yrcrc r ce '
h .
GREASE TRAP:
,locate on site plan)
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:
(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.)
(revised 04/25/97) Page 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Add ess:
Owner: / uS}P�/
Date of Inspection:
TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection)
(locate on site plan)
Depth below grade:
material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain)
Dimensions:
Capacit`: gallons
Design flow: gallons/da%
Alarm level: Alarm in working order_ Yes; _ No »
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX: Nome
(locate on site plant
Depth of liquid level above outlet invent
Comments:
(note if level,and dis}r}bution is equal, evidence of solids carryover evidence of leakage into or out of box, etc.)
PUMP CHAMBER:_
(locate on site plan)
Pumps in working order: (Yes or No) y
Alarms in working order (Yes or No)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(raviaed 04/25/97) Page 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 3/ WAi /es /,�, f /W
Owner: A,S$ l e�� �- e�6 c�i X K��ii7C
Date of Inspection:
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: / ► J�.'1 k%o�i :7 'plr�
leaching fields, number, dimensions:
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments:
(note condition of soil signs of hy�raulic f lure, I vel of,ponding, condition of vegetation, etc.)
eve �h p6c
m u r
CESSPOOLS: _
(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 (cesspool must be pumped as part of inspection)
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.)
(revised 04/25/97) Page 8 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: -3/ G!/.-,4�-.es 4--e Co. t
Owner: ,&t5-ell y- Jar,4�/, ��/�•!
Date of Inspection:
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)
3• ,ss
70
A
• 1 �J
' N
I II'
(n 7d $ V)
J �v/r oti� J
..�— —4-d
(reviaad 04/25/97) Page 9 0L 10+' 'S
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: -31 Gv,41
.2iti r 1�-ti-e Cow,'/-
Owner: Ak SSA�� fN�i��� �Li r fe
Date of Inspection:
— 7 �— q�
Depth to Groundwater 4 / Feet
Please indicate all the methods used to determine High Groundwater Elevation:
C-f-Obtained from Design Plans on record
_/Observation of Site (Abutting property, observation hole, basement sump etc.)
l/betermine it from local conditions
Check with local'Board of health
Check FEMA Maps
Check pumping records
_Check local excavators, installers
Use USGS Data
Describe in your own words how you established the High Groundwater Elevation. Must be completed)
GfflAg /VI�i,/�f c1� /v�l/H �I�l/
dif 14,1 Cl
(revised 04/25/97) Page 10 of 10
Z. �j03 498 575
US Postal Service
Receipt for Certified Mail
No Insurance Coverage Provided.
Do not use for International Mail See reverse
Sent to/
Sire
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Po ice, te,& Code
Postage
Certified Fee
Special Delivery Fee
Restricted Delivery Fee
LO
Return Receipt Showing to
Whom&Date Delivered
Retum Receipt Showing to Whom,
Date,&Addressee's Address
QTOTAL Postage&Fees $
co) Postmark or Date
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Stick postage stamps to article to cover First-Class postage,certified mail fee,and
charges for any selected optional services(See front).
1. If you want this receipt postmarked,stick the gummed stub to the right of the return
address leaving the receipt attached, and present the article at a post office service a
window or hand it to your rural carrier(no extra charge).
2. If you do not want this receipt postmarked,stick the gummed stub to the right of the 0)
return address of the article,date,detach,and retain the receipt,and mail the article. ILO
I 3. If you want a return receipt,write the certified mail number and your name and address rn
I on a return receipt card,Form 3811,and attach it to the front of the article by means of the _
I gummed ends if space permits. Otherwise,affix to back of article. Endorse front of article
RETURN RECEIPT REQUESTED adjacent to the number. Q
4. If you want delivery restricted to the addressee, or to an authorized agent of the O
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addressee,endorse RESTRICTED DELIVERY on the front of the article. ^M
5. Enter fees for the services requested in the appropriate spaces on the front of this " ,9
receipt. If return receipt is requested,check the applicable blocks in item 1 of Form 3811-1 io
6. Save this receipt and present it if you make an inquiry. t o2595-97-B-ot 45 U
EVE Town of Barnstable
Department of Health, Safety, and Environmental Services
• tARN9TABLE, i
9� Public Health Division
P.O. Box 534, Hyannis MA 02601
Office: 508-790-6265 Thomas A.McKean,RS,CHO
FAX: 508-790-6304 Director of Public Health
August 27, 1998
Mr. White Russell & Judith
31 Whites Ln.,
Santuit, MA 02635
NOTICE TO ABATE VIOLATIONS OF THE TOWN OF BARNSTABLE
REGULATION REGARDING FUEL AND CHEMICAL STORAGE SYSTEMS
Our records indicate that you have an old underground fuel oil tank located at 31 Whites Lane,
Santuit, MA . This tank is listed on Parcel 027 on Assessor's Map 003 and registered as tank tag
#183.
This tank is located in a critical zone of contribution to our public drinking supply wells and is 20
years old or older. You must have your underground tank removed within 30 days from the
receipt of this order letter.
For the removal of the tank you must first obtain a removal permit from the Fire Department. I
have enclosed tank removal information for you. Upon removal of your tank, please return valve
tag# 183 to the Health Department.
You may request a hearing before the Board of Health if written petition requesting same is
received within seven (7) days of receipt of this notice.
Sincerely yours,
omas A. McKean
Director of Public Health
Enclosure: Tank Removal Information
G
F Cotuit Fire Department TOLI U
440
Fire, Rescue & Emergency Services GO l�
o 4 64 Hig h St. - P.O. Box 1632
J
�i9:6 Cotuit, MA 02635
RES�
Paul A. Frazier Phone (508) 428-2210
Chief of Department FAX'(508) 428-0202
TO: Tom McKean, Director of Public Health
Town of Barnstable, Board of Health .
P.O. Box 534 '
Hyannis, MA. 02601
FROM: Chief Frazier, Cotuit Fire Department
SUBJECT: Tank Removals, et al o 66
DATE: September 15, 1998
The following tanks have been removed/abandoned since my letter dated March 25,
1998. If you should have any questions or need additional information, please feel free to
call.Thank you.
NAME ADDRESS DATE NOTES
Andelton CC-23randywine Ct. 09/03/98 2000 gal. tank removed,
Cotuit, MA. 02635 no contamination or odor
present.
White 31 White's Ln. 09/15/98 300 gal. tank removed,
Cotuit, MA. 02635 no contamination or odor
present.
Enclosing Valve Tag#186 for 31 White's Ln., Cotuit (Refer to attached copy of letter,
should read Valve Tag #186 and not#183).
f .
Town of Barnstable
BARN3IABLE : Department of Health, Safety, and Environmental Services
6`. ,�� Public Health Division
prFD�AA�� P.O. Box 534, Hyannis MA 02601
Office: 508-790-6265 Thomas A.McKean,RS,CHO
PAX: 508-790-6304 Director of Public Health
August 27, 1998
Mr. White Russell & Judith
31 Whites Ln.,
Santuit, MA 02635
NOTICE TO ABATE VIOLATIONS OF THE TOWN OF BARNSTABLE
REGULATION REGARDING FUEL AND CHEMICAL STORAGE SYSTEMS
Our records indicate that you have an old underground fuel oil tank located at 31 Whites Lane,
Sa tuit, MA . This tank is listed on Parcel 027 on Assessor's Map 003 and registered as tank tag
This tank is located in a critical zone of contribution to our public drinking supply wells and is 20
years old or older. You must have your underground tank removed within 30 days from the
receipt of this order letter.
For the removal of the tank you must first obtain a removal permit from the Fire Department. I
have enclosed tank removal information for you. Upon removal of your tank, please return valve
tag # 183 to the Health Department.
You may request a hearing before the Board of Health if written petition requesting same is
received within seven (7) days of receipt of this notice.
Sincerely yours,
omas A. McKean
Director of Public Health
Enclosure: Tank Removal Information
TOWN OF BARNSTABLE
3i f�/��tsH2
LOCATION SEWAGE#
VILLAGE ASSESSOR'S MAP& LOT 027-003
INSTALLER'S NAME&PHONE NO. 1,
SEPTIC TANK CAPACTTy /emu
/= /rOU ��tie�,�,f
LEACHING FAClLrrY: (type) , (size)
NO.OF BEDROOMS
r
BUILDER OR OWNER 11Z 5 S-e1 l 1-
PERMTTDATE: COMPLIANCE DATE:
Separation Distance Between the: ,
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) U '"d�`°p� Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
t
aS�
Q �
No.... 7...... FEs..... .................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HE L
( jt I&Kk `------- ---.OF..... . C,���c y
2 ...................
V
C Apptiration .for Uiipnsal WarksCann rn ann ernti
Application is hereby made for.a Permit to Construct (� or Repair ( ) an Individual Sewage Disposal
System at:
A.2_ - itg lAtn J� f , Y_ LLII.s-- ......-•-----------•------...•----•••....--•---•----•----------•---.....-•----------------------.
Location-Address or Lot No.
- 1.ti.)ln.i-1Q x_.._ `� ._`t.. a nr�� n i e ........
Owner Adlres xr
aha lJ �-�--------------------------------------------
Qom-}ht 'Iw,
I
nstaller Address
Q Type of Building Size Lot--------35,6P-0-----Sq. feet
U Dwelling—No. of Bedrooms---_-_Z................................Expansion Attic ( ) Garbage Grinder ( )
14 Other—T e of Building ____ No. of persons__..a3 Showers — Cafeteria
Q Other fixtures ...................................
-------------------------------------------------------------------------------------- --------------------
W Design Flow___________________________I__ _____gallons per person per day. Total daily flow...............J....... -----------gallons.
Septic Tank—Liquid capacity............gallons Length................ Width---------------- Diameter---------------- Depth................
W 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 ( )
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......_-___-_---_______-
0 Description of Soil.................... ---•---•------------------------------•--------------------------------------------------------------------------------------------------------
x
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 Article XI 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 b and of alth.
!��
/Application Approved ate
_ -- - ----------------------- /
ate
Application Disapproved for the following reasons:----------•-•--•-----•----------------•-----••-•-----••--•-----•-•-------•-•----------------------•------•••-•-•
•-----------------•----------•------•--•----•-•-----------------••--•---- --------.....--------------•••-•--•-•--•--------•-------••--------•----•----...........................................
e� Date
PermitNo......................................................... Issued........... . 7
Date
No...377....... Fxx.....21.................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
_ ......................OF..................................---....------------------------------------------------
Appliration for Miposal i8arko ( omarurf ou Prrmit
III Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal
PP Y (✓J
System at:
Jlr ._ �i►�g .. n _ �? u-ti ;..Y_ __l 0.........-- --•------------------------------•----•-----------....------------------..........---•--------.....
/� ocation-Address or Lot No. i
Qwner Addr
.. ........
�j�4►5 t. . _.S9-l-s�o�1 .._l�o�.a__:.. ..._. 04_�4► Q �'�yR
Installer Address
QType of Building Size Lot------35,0.9.0------Sq. feet
U Dwelling—No, of Bedrooms....
__ Expansion Attic ( ) Garbage Grinder ( )
�...{ ............ .
Other—Type of Building ............................ No. of persons........ Showers ( ) — Cafeteria ( )
a' Other fixtures _____________________________........
---- -- _ ----
W Design Flow...................... ........ .gallons per person per day. Total daily flow_........._.._...___ .......---gallons.
WSeptic Tank—Liquid capacity/ --gallons Length................ Width---------------- Diameter---------------- Depth-------------
x Disposal Trench—No..................... Width-------------,,_�/,f,�Total Length--------.___ Total leaching area..._ sq. ft.
Seepage Pit No... Diameter.�� `Llepth below inlet___.._��_.._._ Total leaching area.���---sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by------------------------------------••••-•-•--•------•---------------•--• Date--------- -----_----------------------
,� Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water--------------:.........
�t=•1 Test Pit No. 2................minutes per inch Depth of Test Pit___--_-_---______- Depth to ground water------------------------
a ---•--. ----------•..............................................................................................
O Description of Soil..............' -------
x
V ................................................ ----------------------••---------------------------------------------------------------------------------.
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 Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
S e � � P" .-- 1� -------------------------
Dat
Application Approved BY e -- -- ;
ate
Application Disapproved for the following reasons----------------_ --------------------------------------------------------------------------------------------
Date
PermitNo.......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
,nw
BOARD OF HEALTH
s....... ...............OF.......49. .................................................
i' rrttftra of (waaittp.laan ae
T� 1 IS TO C R ITY Tha t Individual Sewage Disposal System constructed (�/' ) or Repaired ( )
b = - --------------
Y
ller. --------------
'bed at Y=l -------------------------------- - - `~
has been.installed in accordance with the provisions of-Article XI of The State Sanitary de s de criiZbred m the
application for Disposal Works Construction Permit No..................37...7_.�.... dated._-, _3,��_.__...__.____...__..
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM �N/�ILL7?7-j
TJN SATISFACTORY j,
.° Inspector;
THE COMMONWEALTH OF.,-MASSACHUSETTS j
BOARD qF HEALTH' ,. .
*� �.......OF..... .... i...�.. - -------------------------------------------
..... FEi ---------•-•-•--
; x aaa�� rtzrt�l�it a?�Iltt�
Permissio hereby granted.._. OLZ_. ___6A_........... .�
------------------ -
to Constructo �R air ( 7..an Individua ewa ispo ]�5ystem
1.
at No..--• -------,,. r:.�--------------------------------------------------- .............
Street n,
as shown on the application for Disposal Works Construction it No___ _______________ Dated_ ___f_V�__`_--.-.-
• ��� ----------------=------- --=
-=' Board of Hea1tU
DATE--- - �..- ---7__ ------------------------------------------
FORM 1255 HOBB & WARREN,'INC.. PUBLISHERS