HomeMy WebLinkAbout0105 WILD WAY - Health 105 Wild Way, Cotuit
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COMMONWEALTH OF MASSACHUSETTS
t EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET. BOSTON. MA 02108 617-292-5500
V,V
WILLIAM F.WELD TRUDY COXE
Governor Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner
PART A
CERTIFICATION
Property Address: 105 Wild Way, Cotuit Address of Owner: Kathy Converse
Date of Inspection: //;-q— 9 ,7 (If different)
Name of Inspector: Wm E Robinson Sr
I am a DEP approved system inspector pursuant to Section 15.340 of Title MR 15.0
Company Name: WM E Robinson Septic Service
Mailing Address: PO Box 10890 n prvi 1 1 a , MA 0263
Telephone Numbers -5 00 8 7 7 5—A 7 7 6
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that t tion re o ow 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:
_b Passes
_ Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: Date: [ ;L
The System Inspector shall 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:
A] SY TEM 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:
B SYSTEM CONDITIONALLY PASSES:
One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon
completion of the replacement or repair, as approved by the Board of Health, will pass.
In icate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. 4-dot,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 I.of 10
DEP on the World Wide Web: http:l/www.magnet.state.ma.us/dep
ej Printed on Recyded Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 105 Wild Way, CotUlt
Owner: Converse
Date of Inspection: //;.41— 9 1
B] SY TEM 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] FURTHE EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Con 'tions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public ealth, 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) S EM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
TH SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENV ONMENT:
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 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) OT R r:
(revised 04/25/97) Page 2 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 105 Wild Way, Cotuit
Owner: Converse
Date of Inspection: 4/ �f
D] SYSTEM FAILS:
You ust indicate ei;!;er "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
orthis determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
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 clogged SAS or
cesspool.
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 pipeW.
Number of times pumped _.
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well
Any portion of a.cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water=quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
EJ LA GE SYSTEM FAILS:
You st indicate either "Yes" or "No" as to each of the following:
The following criteria apply to large systems in addition to the criteria above:.
he system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to
blic health and safety and the environment because one or more of the following conditions exist:
Yes N
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)
The owner r operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requiremen s of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 04/25/97) Page 3 of 10
Y
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 105 Wild Way, Cotuit
Owner: Converse
Date of Inspection:
Check if the following have been done: You must indicate either "Yes" or"No" as to each of the following:
YQs j 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.
— The facility or dwelling was inspected for signs of sewage back-up.
— The system does not receive non-sanitary or industrial waste flow.
— The site was inspected for signs of breakout.
All system components, excluding the Soil Absorption System, have been located on 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.
L / The size and location of the Soil Absorption System on the site has been determined based on:
V 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))
J)
Y,
(revised 04/9S/97) Page 4 of 10
4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 105 Wild Way, Cotuit
Owner: Converse
Date of Inspection: 7
FLOW CONDITIONS
RESIDENTIAL:
Design flow: � 0 .p.d./bedroom for S.A.S.
Number of bedrooms:Z--od
Number of current residents: 3
Garbage grinder (yes or no):�a
Laundry connected to system (yes or no, _S
Seasonal use(yes or no):ti0
Water meter readings, if available (last two (2) year usage (gpd): 1996 — 1 2 6 , 0 0 0gal s
Sump Pump (yes or no):w 1997 — 1 50, 000gals
Last date of occupancy: e L-4
C MERCIAUINDUSTRIAL:
Type f estabhshment:
Desig flow: gallons/day
Grease trap present: (yes or no)_
Industri I Waste Holding Tank present: (yes or no)_
Non-sa itary waste discharged to the Title 5 system: (yes or no)_
Water eter readings, if available.
Last ate of occupancy:
OT tR-: (Describe)
Lasof occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
.t./r'A
System pumped as part of inspection: (yes or no) C ,S
If yes, volume pumped:l60� gallons _
Reason for pumping: 7?Lp oo G 1- 3 S t'Z�'
t. %0 �
TYPE OF STEM
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
I/A Technology etc. Copy of up to date contract?
Other
APPROXIMA7E AGE of all components, date installed (if known) and source of information: A.,&s SAS
Sewage odors detected when arriving at the site: (yes or no)A,
(revised 04/25/97) Page 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 105 Wild Way, Cotuit
Owner: Converse
Date of Inspection: /`����r� 7
BUI DING SEWER:
(Local on site plan)
Depth ow grade:
'Material f construction: _cast iron _40 PVC_other (explain)
Distanc from private water supply well or suction line
Diame r
Com ents: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK:_v
(locate on site plan)
Depth below grader
Material of construction: oncrete _metal _Fiberglass _Polyethylene _other(explain)
If tank is metal, list age — Is age confirmed by Certificate of Compliance —(Yes/No)
Dimensions:
Sludge depth:_ ►
Distance from top of sludge to bottom of outlet tee or baffle: Li a
Scum thickness: 0 ► 2 `
Distance from top of scum to top of outlet tee or baffle: F ►
Distance from bottom of scum to bottom of outlet tee or baffler
How dimensions were determined: 10 4 A-- JL- G/�� a s•.• )d e^-l�
Comments:
(recommendation for pumping, condition of i let and outlet tees or baffles, depth of liquid level in relation to outlet inyert,��uctural
integrity, evidence9f leakage, etc. T �S f v►—
C� tb a a
GRE SE TRAP:
(locat on site plan)
Depth below grade:
Mater' I of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain)
Di sions:
Scum thickness:
Distan a from top of scum to top of outlet tee or baffle:
Distanc from bottom of scum to bottom of outlet tee or baffle:
Date of st pumping:
Comment
(recomme dation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, vidence of leakage, etc.)
LL
(revised 04/25/97) Page 6 of 10
c
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 105 Wild Way, Cotuit
Owner: Converse
Date of Inspection:
TIG TOR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection)
(locate n site plan)
Depth low grade:
Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain)
Dimen ions:
Capac ty: gallons
Desi flow: gallons/day
Alarm vel: Alarm in working order _Yes; _ No
Date of previous pumping:
Comme ts:
(conditi n of inlet tee, condition of alarm and float switches, etc.)
AZ
DISTRIBUTION BOX.—
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal, evidence of solids car ver, evidence of I ak�g t�nt r out of x, etc.)
PUMP HAMBER:_
(locate o site plan)
Pumps ' working order: (Yes or No)
Alarms in working order (Yes or No)
Corn ents:
(note ndition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 04/25/97) Page 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 105 Wild Way, Cotuit
Owner: Converse
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS): Y
(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: %Z� °°°"���n s
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
/_ti'1.�J . I L L a h
3 .
CE POOLS: _
(Iota on site plan)
Num r and configuration:
Depth- p of liquid to inlet invert:
Depth f solids layer:
Depth f scum layer:
Dimen ions of cesspool:
Mater' Is of-construction:
Indic tion of groundwater:
inflow (cesspool must be pumped as part of inspection)
Com ents:
(note ondition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:
(locate on site plan)
Materials f construction: Dimensions:
Depth of olids
Comments
(note co
tion of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 04/25/97) Page 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 105 Wild Way, Cotuit
Owner: Converse
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)
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(revised 04/25/97) Page 9 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 105 Wild Way, Cotuit
Owner: Converse
Date of Inspection:
X
Depth to Groundwater 16 Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observation of Site (Abutting property, observation hole, basement sump etc.)
Determine 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)
(revised 04/25/97) Page 10 of 10
No. � 1 Fee $50 .00
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
If Zipplicatiou for Digo.5al *proem Con!6truction Permit
Application for a Permit to Construct( )Repair(x�Upgrade( )Abandon( ) El Complete System El Individual Components
i.
Location Address or Lot No. 1 0 5 Wild Way Owner's Name,Address and Tel.No. 4 2 0—3 5 6 0
Assessor'sMap/Parcel Cotuit, MA 02635 Thomas & Catherine Converse
Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No.
P - Wm E Robinson Sr Septic Sry
PO Box 1089 , Centerville, MA 0263
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder( n)o
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 sand
Nature of Repairs or Alterations(Answer when applicable) Title 5 Septic Repair
Leaching consisting of new D-Box, and 3 stonepacked H-20 infiltrators.
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 b th' o of Health. )> _
Signed r _ Date//`'�`��
Application Approved b Date -/Z- 2f�7
Application Disapproved for the following reasons
o. e' Date Issued
I.1Y/�..:ri • .. yr• .. ... .. .. .. 14.*nj.. .r. .. M
fI �.�Y►..� f. a ///•�/J//�• ^(/��[ h.. //�J * ...... !(,'V' g. .
No. �7 � �<r � Fee
50 0 0 1
I C
' THE COMMONWEALTH OF MASSACHUSETTS
Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS
01pprication for Digpogar *pgtem Con0truction Permit
Application for a Permit to Construct( )Repair(XX Upgrade( )Abandon( ) ❑Complete System'"❑Individual Components
Location Address or Lot No. 105 W i l d;Way Owner's Name,Address and Tel.No. 4 2 0—3 5 6 0
Assessor's Map/Parcel` Cotuit, 1dA 02635 Thomas & Catherine Converse
Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No.
Wm E Robinson Sr Septic Sry
PO Box 1089, Centerville, MA 0263
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( no
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 sand
Nature of Repairs or Alterations(Answer when applicable) Title 5 Septic Repair
Leaching consisting of new D-Box, and 3 stonepacked H-20 indiltrators.
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance withahe provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Ccmpliance has been issued by th' o of Health.
�a
—signed r l Date
ApplicationlApproved by _ Date � ��
Application Disapproved for the following reasons r
r
Permit No. '` 4 Date Issued
----------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Conv ':e'§'e,,, ,.,,Certif Kate of Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( ) Repaired (Xx) Upgraded( )
Abandoned( )by
at ' 05. Wild Way, Cotuit as been constructe in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No " dated 7
Installer Wm E Robinson Sr Spt Sry Designer
The issuance of this permit shall not be construed asr a..guarantee that the system will function as designed.
Date 1 1' a�1 7 Inspector
`�1
a
No. .r. #: ;; Fee$50.00
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
Converse 30i.5pogal *pgtem Con.5trurtton Permit
Permission is hereby granted,t6 Construct( )Repair(X:�Upgrade( )Abandon
System located at 105 Wild Way_
Cotuit, MA
Installer Wm a*-Robinson Sr Sept Sry
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to f
comply with Title 5 and the following local provisions or special conditions. f'
Provided: Construction must be completed within three years of the date of this it.
Date: / ! Approved %" ,i
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic. Systems Only._
CERTIFICATION OF SKETCH AND APPLICATION FOR A
DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT
ENGINEERED PLANS)
I, William E.Robinson.-Sr.- ,.hereby certify that theapplication for disposal works
construction permit signed by me dated ,���'1� concerning the
property located at 105 Wild Way,Cotuit..MA,_ meets all of the
following criteria:
Mere. re.no wetlands.within 100 feet-of thc.proposed.leaching.facility.
* r private 11 within 1 e no p ate wells wit 50 feet of the proposed septic system.
*The i no increase in flow
s cease ow and/or change in use proposed.
* The are no variances requested or needed
* If.the.proposed.leaching.facility.will.be_located with.25.0.feet.of any wetlands,.the.bottom of the
proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted
groundwater table elevation.
Please complete the following:
A)Top of Ground Elevation.(according to.the Engineering Division G.I.S. map).. 7143
3
B)Observed Groundwater Table Evaluation(according to Health Division well map)
SIGNED:._ . �: DATE 4��
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER 60
(Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan,
this plan should.be submitted).
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TOWN OF BARNSTABLE
LOCATION SEWAGE#
VILLA'.F I" a r4 7 ASSESSOR'S MAP& LOT �3
INSTALLER'S NAME&PHONE NO. RE
SEPTIC'TANK CAPACITY
i/
LEACHING FACILITY: (type) 4s'ize)
NO.bF.BEDROOMS .3 l
BUII bER OR OWNER
PERMr-rDATE://_,a./_q '7 COMPLIANCE DATE:&";z I'" q 7
Separation Distance Between the:
Ma iiium Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on..site or within 200 feet of leaching facility) Feet
Edge.of Wetland and Leaching Facility(If any wetlands exist
wtliin'300 feet of leaching facility) Feet
Furnished by
i
00
TOWN OF BARNSTABLE
LOCATION f'f5 GU �I c.� ��� ��_ SEWAGE # ,� `� 3
,VILLAGE 6f 92'I f A'j - ASSESSOR'S MAP & LOT-21120 63
,INSTALLER'S NAME&.PHONE NO. � e5 . �- a �"` 7•�`'
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) v 0 (size)Il�
J NO.OF BEDROOMS 3
BUILDER OR OWNER e—ca
PERMrfDATE:/Z— -%-9 '7 COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility. Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on'site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet ofleaching facility) f Feet
Furnished by
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THE COMMONWEALTH OF MASSACHUSETTS T
BOARD OF HEALTH
ro..Gc......�..............OF........ Lfz,C� � -��L. ...................
Applutt#inn for Disposal Narks Tonstrwtfun Farm#
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
...._.« tee....Location
--..• - •. o Lot.N.« .. ..... «.........
Ow _-_ Address
a ++++++- .............................. ................
.... - .............•-•• -• - �C` -ram._......... .......
Installer Address
Type of Building Size Lot Zqq ....24V....Sq. feet
aDwelling—No. of Bedrooms._....&................:..............Expansion Attic ( ) Garbage Grinder ( )
a Other—Type of Building ............................ No. of persons............................. Showers ( ) — Cafeteria ( ) ...r
Other
WdW Design Flow. �� res-..............-_gallons per person per day. Total daily flow...,.a�. .6.......................:.gallons.
WSeptic Tank—Liquid capacity............gallons Length.............. _ 'dth............... Diameter................Depth.-..............
Disposal Trench—No................ Width................. Total Length._.._./...............Total leaching area-........._.---_ sq. ft.
3 Seepage Pit No....I........ ...... Diameter._:�.0......... Depth below inlet...&............ Total leaching are . :Ysgr. ft.6 P4
Z Other Distribution box Dosing....
tank ( )
Percolation Test Resul�� Performed b ...Lei tf-Ll.......a).EL � /. Depth to Date.
211
wwater... ..
,.a Test Pit No. L.-------------minutes per inch Depth of Test Pit.. ... ep ground /v I..O
Gi. Test'Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a ......................................................................••-••-•--•-........................................... --------------
O Description of Soil........................................:
.................................� ��-. :.:.....................................
:::::::::: :::::::._:: :..::::._::::::--- - ... . --::::..:::::
w ;
•-
UNature of Repairs or Alterations—Answer when applicable...............................................................................................
---•----••----•.............•--•-----......--•--.:•......-----...........---........-------------•----..........:----------------•-••----------..........:........--•---........._............-••-_.....
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the rovis is of iII lS 5 o e State Sanitary Code— The undersigned further agrees not to place the system.,in
o ation t o Certi pliance has been is a d o health.
Sit ---------------- ••.......•....... ..... �:.. . .. a
Applicati PProved By........ ----• •. ........ -• ......•-••••......-•-•••. ¢ l .
Dye ✓�
Application Disapproved for the f ollo reasons----------------•---•-•---------••--••...---•----------•---.....................•---•_... .
, .
Permit No....... = . ....................... Issued.................................
.......... ........
--•--
Date
F$s.......
! _.
THE COMMONWEALTH OF MASSACHUSETTS r —•
BOARD OF HEALTH
'l
- O- ..............OF........ �?,t /+ 4.�.�...................
Appliration.-Jar 11ispoottl Iforks Tonstrurtiort 11rruiit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal,
System at: `.
.............................. ...... ........� .7:".. .._ .. ..---------•---
Location-Add
re s ^�/? �„�- or Lot No'.- L
T Address
Own r
.... ............^_.................. I stall .............. .--•-•-.._....-•-•---•- • _., ........Address -- • ..............................
i r
<< _ Type of Building Size Lot:ZO._��1��----Sq. feet
.., Dwelling—No. of Bedrooms.._...1•;�r__ _______________________________Expansion Attic ( ) Garbage Grinder ( )
~Other—T e of Building No. of ersons____________________________ Showers
fs, YP g -•-----------------------•-- P ( ) — Cafeteria ( )
Otherfixtures ................•-------•--------....._..---•-----._..._.....------------------•---•--------.._........-----•--------••-•--•---•----..._......-•-----•
i WW Design Flow... '•.4Z24a........................gallons per person per day. Total daily flow... ...........................gallons.
i W Septic Tank—Liquid capacity............gallons Length................ Width.........._..... Diameter................ Depth................
x Disposal Trench—No..................... Width....r_.._....._....Total Length_.___......._...__. Total leaching area...................sq. ft.
3 Seepage Pit No....I............... Diameter...)4.......... Depth below inlet... �?._......... Total leaching area:5- :Ksq-ft.6 P
Z Other Distribution box O, Dosing tank •
aPercolation Test Results Performed by._(-..6 Ems._ ._.....�� .P...L_4:..r�_..%,tel .. l ___ I.... Date... , K�m r
Test Pit No. 1................minutes per inch Depth of Test Pit..i44..`�. .... Depth to ground water.._ !�)_f:__
f=, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water_:__._..........._..___.
x
D •.....:......------••--•�-•••--••---------------------------------------------------------------------------------------•-_.....
Description of Soil---------------•--------•-•------•-- •--•••...._...._.
-------------•-...........•-- =`>r, - 'J - - ... - - ... ... ...-----
UW ••--••-.._...._..._...--•---•-------------------•-----------------------------._..._..-•-•--------•.._._...._...--------•-----------••-•-•---•-••-----•--•._................•-•-•••--•--••...._••-_..._.
Nature of Repairs or Alterations-Answer when applicable............................................:..................................................
........................ = ..... -------------------------------
..........__-- -----•---•- ---------------------------
-...........
_----------------------------------
...............
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provistgtis of iITI. 5 o e State Sanitary Code—The undersigned further agrees not to place the system in
o ation a Certificat ompliance has been issued by-the b'oa d o•health.
^' `
SW - -------------- --..._••-- =�_, .. .�.�' ._.
w_J ;.
DDate
Applicati pproved B f �) /
A Application Disapproved for the follourin reasons:.................
.........................................................................................---
................................•----••---•--•-••---.....----•--•-----------._......_._.....-------._.._...----..__........._.__....-------•=---•--------------••------..._.....---••-••-•----••......_
'
Permit No.-------•---.7..-._...--•�/'---�--•----------e----_�..� Issued.......................................... ate._.........
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......`k°. !1-I&.: ........OF........... f�°�11/trt...................: ��--�.........
Trr#ifiratr of Toutphiturr
THIS IS TO CERTIFY; That the Individual Sewage Doiisposal System constructed ( ) or Repaired ( )
by..........................................................1 ; --1 - =iRgtai...y U ----..-------...--••-----------------•-•-••--•---•-----....,4.a 3- -'
i 1 ` - )1 l tit �i�/1 S .
at...... . .. .......... .......... • " -•--- - ----- -- -- -••---•-------------------•-•-•-•••-•----••--•--------------•---'---•------
f-•--...._...--
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Cpde as described in the
...
application for Disposal Works Construction Permit No.__�,!__]q__ -_...__ 4___________________ dated__---__� ........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE-T_ AT THE
SYSTEM WILL FUNCTION SATISFACTORY. T /
DATE............... t � ..--... / �.... :. � �----- Inspector � .... -- -.....
y --�,`
--------- ---------------- --------_----------------------------- -----,
VTHE COMMONWEALTH OF MASSACHUSETTS
f 3�.
BOARD OF HEALTH
.................� . :.OF.--------.. -wv ......... -
No. ................. Fxs �...........
DispoottlAVorko Tonotrurtiott Errant
Permission is hereby granted--•--._..._.._. . .. ..� ............................................................................__._
to Construct ( ) or Repair ( ) an Individual. Sewage Disposal System
at No......_.rat *� ..._._. �...` �.L t � h,)r tJ`;?�..... ...........i,;:� , `,�� ,...................
l �_::.... ...... .............
w
J/ Street V
as shown on the application for Disposal Works Construction=PermitNo._,,2:n.��:.�. D'ated.._ ..'".w...:` �.............
/ Board of Health
DATE.............. ed�2.............................