HomeMy WebLinkAbout0002 OAK STREET - Health 2 Oak
A=310-] 93 i
t�.
TOWN OF BARNSTABLE COMPLIANCE: CLASS: 1. " arine,Gas Stations,Repair
satisfactory 2.Printers
BOARD OF HEALTH 3.Auto Body shops
0 unsatisfactory- 4.Manufacturers
COMPANY `�c4r v b ez,- ` (see"Orders") 5.Retail Stores
6.Fuel Suppliers
ADDRESS ��'I Class: 7•-Miscellaneous
2,9Z,�_ , ITIES AND STORAGE (IN= indoors;OUT=outdoors)
MAJOR MATERIALSCase lots Drums Above Tanks Undergrqund T
IN OUT IN OUT IN OUT #&gallons Age Test
Fuels:
Gasoline,Jet Fuel (A)
Diesel, Kerosene,
Heavy Oils:
waste motor oil (C)
new motor oil (C)
transmission/hydraulic
Synthetic Organics:
degreasers
Miscellaneous:
n P -
L
DISPOSAURECLAMATION REMARKS:
1. Sanitary Sewage 2. Water Supply AEI -./
Pla�je&
O Town Sewer NPublic
XOn-site OPrivate
3. Indoor Floor Drains YES NO
O Holding tank:MDC
O Catch basin/Dry well
O On-site system
4. Outdoor Surface drains:YESZNO ORDERS:
O Holding tank: MDC '
gCatch basin/Dry well d
On-site system
5.Waste Transporter i
Name of Destination Waste Product
YES NO
2.
Person (s • nterviewed- Inspector Date
FE$......�. .:.......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
,,..........OF...........�.� ..... -------------• .........
Appliratiun for llispuiitt1 Works Tomilrnrtiun Vamit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
::.......... -r •--- ......----•• ----•-•........••••-•-•-•••----------------•..... .........-•--•..........--•---............--•-
sK
t'6r1 1 e ....... —or Lot No.
..... L ,. - "' =------------------------ -•--------..............------................
' Owner Address
W207:4� ........................................... ----•-•-••-•........................I..............................................................
Installer Address O
d Type of Building Size Lot...
..............gq. feet
U Dwelling—No. of Bedrooms......._.. ..............................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ... No. of persons Showers — Cafeteria
a YP P �-----_----------- ( ) ( )
dOther 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.................... 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. 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........................
Q+' -----------------
xDescription of Soil.... .... ... ------------•--------------------------------•----••-•-.---•-
U •-•------•-------------•--------.............-------•------•---•---•-----------------•---•----•-----••-•-•--•-----------•--.._.......-------------------•---------------•-----------------------•..-•-•-
W ---•---------------------------------------•----•------••-----------•-•-------•-•••---------•-••------------------------
.--••-•------...
V Nature f Repairs or Alter tions A saver w en applica le____ __________ _ _____ ___________ __ __G......__.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITHE 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed.. .... / .......................
Date
Application Approved By............. ,�,"�. -.. ................................ -•-•-• a
Date
Application Disapproved for the following reasons:..............................................................................................................
-••--•-----------------------•---......-•--•-•-------------•-----•---•-----•---........----••-------•---•._.....-------------•------•-----...----...-------..............................................
g Date
Permit No------- ...-...�� .................. Issued-..:-3�.......` e
Date
F$s........aZil
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...•---.....h" -ern..........OF............ .......................................
Appliratiun for 14spusttl Varks Tonstrurtiun Permit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
........k.......:.!». ...:! !n_:i....e.s Lot No.
..... ............................................ ....................................._..
or
.... •'" .-•' r
-----
Owner Address
a Y... ..................'.............5.............................................. ................................•..............................•........��....... ........
Installer Address
Type of Building Size Lot.... ._'...............Sq. feet
U Dwelling—No. of Bedrooms,."'.
edrooms..:..........t...._........................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building - « .... No. of persons---�.................... Showers ( ) — Cafeteria ( )
QOther fixtures ..---....--••-•-•------•--------------•-•---•-•----•--.•-•---------------------------------.............._...........•--•__..............-••----•-•••-
Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
Septic Tank—Liquid*capacity............gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench-No..................... Width.................... Total Length.................... Total leaching area...................sq. ft.
Seepage Pit No......... ...... Diameter.................... Depth below inlet.................... Total leaching area.................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed bY.......................................................................... Date........................................
0-� Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.........................
(i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
x ¢ ----------------------------------------•-----------••----•-•-•----------------------------------
D Description of Soil....Z .... �...�!�:
------•-..-•-•-•---------------- -----.-----../..----•-•---------_..-...-----------...-..------•-----•............-....
...............................
.---------•--.-..------...---.-------
........................
................................... .... ..--------- •. Z)----"I'l....... .
UNature f Repairs or Alter Ions A swer w n a lica e_... !� ��'
!. .Y! . ........ -t ------------------------------•••--••'•.......--------•-•-......---••---------•--•----'•--.......
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System.in accordance with
the provisions of TITIS 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
3-� - ELSS
Signed---.��_.. .--•........................................ ....................... .........................._....
Date
Application Approved BY ..... _._..� ..-. ..-. _.�fS..
- Date
Application Disapproved for the following reasons:............................................................................................................
...-•-•---'-•••-'---••--•••----••-'----........•••--...••.................................'•-•-----------.........................--•...•---•••-•--•-•-•----•-----------......................_....._.._
A Dale
Permit No.........1a..s...= -�--•-•--•---....-.. Issued
-...
�...._�-•----••'?, �"
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........y `'.ff.::#:Z..:.........OF.............���� Y�r-*�{??���✓Y.............................
Trrtif irate of Turpliana
THIS IS CERTIFY That the Individual Sewage Disposal System constructed ( ) or Repaired
by................... L.......�L(X CERTIFY,
_�......................... /, ........ .......................---------...----•.-'•'-.............._................... ._...._
staller
at.............I......C2.A...S C S..T.t.--•'... ti �.��'j_l..(.-c.............•'----•-••••••---••-•-•-•---........................-•-•--•-- •-----------•-----.
has been installed in accordance with the provisions of TITLE 5 of Th State Sanitary Code as described in the
application for Disposal Works Construction Permit No......_��..:...4----.---. dated.............. ..............................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.........................3.:-...:... .5/........................... Inspector....------....... ..................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
GG . G'.��a............OF.. C3
No....t�..?.)..... F> .... ..::.....
Disposal Marks 9unsfrnrtiun f rrmit
Permission is hereby granted..........Q.
to Construct ( ) or Repair (> an Individual Sew ge D•s oral System
at No............�...._j� .'�.._-�-•-•-••.....�.T.-,........�'��
Street qq
as shown on the application for Disposal Works Construction Per t No. :1.1o____. Dated..........................................
................... .4.. �* -•••--....-'------.....................
Board .
DATE.................. . .......................... ':•-•------..
FORM 1255 A. M. SULKIN• INC.. BOSTON
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Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Department of "
Environmental Protection QED
NOV � 0 1996
WIIIIam F.Govemor Weld �
Trs.u,:;y,e°oea �� Mawr
David B. Struhs
Commie or to t a
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION N ``
C�
Property Address: C41,W7�ry j7/l /191 Address of Owner: as -
Date of Inspection: /f—/-2-96 (If different) NOV 2 0 1996
Name of Inspector: Jain, R 194lr
�
Company Name, Address and Telephone Number:
10�K ya/t � 7e/, 5a8 b/z8.gjp?S ;�Cr
/S'o f.!/Q/.,.,t SJ: Mk rSTo•�t/j'�//s iN�, o�L ti�
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information report ow i i 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:
y Passes
_ Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's S' at re: � G�� ''" Date:
9A,1"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] 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.
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, 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 8/15/95)
One VAnter Straot . Boston,Maaanchuse is 02108 • FAX(617)SWI049 • TW*Wwrie(617)292-UN
43 10mi.e an R•yc+•d PoW
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 2 Oa �t ,S f CP�✓v�ffe. Ap
Owner: /f
Date of Inspection:
BJ 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 ins ion if(with approval of the
Board of Health): /
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 br /ortructed pipe(s). The system will pass
inspection itx(with approval of the Board of Health):
�. broken pipe(s) are replaced
obstruction is removed
CJ FURTHER EVALUATION IS REQUIRED BY THE BOARD OF H TH:
Conditions exist which require further evaluation by th oard 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�,"EALT 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 f a`kurface water
Cesspool or privy.is within 50 fe t of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE 60 D OF THATND PUBLIC WATER SUPPLIER, IF APPROPRIATE)OTECT THE PUBLIC HEALTH AND SAFETY AND HEERMINES THAT
THE SYSTEM IS FUNCTIONING I A MANNER RR
ENVIRONMENT: \�
_ The system has a se ic.tank and soil absorption syste and is within i00 feet to a wtfacx water supply or tributary to a
surface water suppl .
_ The system has a eptic tank and soil absorption system ed is within a Zone I of a public water supply well.
_ The system has septic tank and soil absorption system ants within 50 feet of a private water supply well.
_ The system has a septic tank and soil absorption system and i less than 100 feet but 50 feet or more from a private water
supply well„unless a well water analysis for coliform bacteria nd volatile organic compounds indicates that the well is
free from pollution from that facility and the presence of ammo is nitrogen and nitrate nitrogen is equal to or less than 5
ppm.
DJ SYSTEM FAILS:
I have determined that the system violates one or more of the following failure iteria as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be con \ to determine what will be necessary to correct
the failure. \`
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.
Z
(revised 8/15/95)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 2 oa s'
Owner. ��iae-5
Date of Inspection:
//- Az- 96
DJ SYSTEM FAILS (continued):
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 le s't a 1/2 day flow.
Required more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
_ � pumping in P g
Number of times pumped
Any portion of the Soil Absorption System, cesspool or pri is below the high groundwater elevation.
Any onion of a cesspool or privy is within 100 feet f'a surface water supply or tributary to a surface water supply.
_
Any portion of a cesspool"pr privy is within a Zoe I of.a public well.
Any portion of a cesspool or privy is within 0 feet of a private water supply well.
_ Any portion of a cesspool or privy isi,le�As 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 compopnds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS: /fr
The following criteria apply to la ge systems in addition toile criteria above:
The design flow of system is 0,000 gpd or greater (Large System and the system is a significant threat to public health and safety
and the environment beta a one or more of the following conditigns exist:
the system is ithin 400 feet of a surface drinking water supply
the syste is within 200 feet of a tributary to a surface drinking\v�ater supply
_ the sy tem is located in a nitrogen sensitive area (Interim Wellhead otection Area (IWPA) or a mapped Zone It of a
pu tic water supply.well)
The owner or oper for of any such system shall bring the system and facility into full complt nce with the groundwater treatment program
requirements of 4 CMR 5.00 and 6.00. .Please consult the local regional office of the De nt for further information.
(revised 6/15/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 2 Oak SriCrh Ter v>ll e IW4'
Owner: r/i a.►n s
Date of Inspection:
Check if the following have been done:
✓Pumping information was requested of the owner, occupant, and 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.
_�f`As built plans have been obtained and examined. Note if they are not available with N/A.
VThe facility or dwelling was inspected foe signs of sewage back-up.
_!:"*T-he 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.
ZThe size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
_Jfhe facility owner (dnd occupants, if different from owner) were provided with information on the proper maintenance of Sub-
Surface Disposal Svstem.
(revised 8/15/95) 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 04de SA, `Prr vei/dl c
Owner: R/I W/;f/1'
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow: Gallons
Number of bedrooms:
Number of current residents:_
Garbage grinder(yes or no):_
Laundry connected to system (yes oXno):
Seasonal use (yes or no):_
Water meter readings, if available:
c ,
Last date of occupancy:
COMMERCIAUINDUSTRIAL:
Type of establishment:
Design flow:330 t Rallons/day
Grease trap present: (yes or no)
Industrial Waste Holding Tank present: (yes or no)4v
Non-sanitary waste discharged to the Tit}e 5 system: (yes or no)-901 Ll
Water meter readings, if available: l �9 9`� S6.®O O0 4 g gS 90002,J)
Last date of occupancy: j l- /x-9 STi / vceu�ireof
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as part o inspection: (yes or no)=
If yes, volume pumped: Gallons
Reason for pumping:
TYPE QF SYSTEM -
Septic tank/IN be /soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
Other(explain)
APPROXIMATE AGE of all components, date installed (if known)and source of information: P yy«rt i 5&1/V �3-
re0` 'L&{ 6.0r".5tell✓ J0.4,rj 07 ge*//h
Sewage odors detected when arriving at the site: (yes or no) J110
(revised 8/15/95) S
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: Qa h 5T Ceo rrV1,11C X&,
Owner: 1?./q, l(/,�ll�prrS
Date of Inspection:
/�L- 96
SEPTIC TANK:_
(locate on site plan)
Depth below grade: /
Material of construction:7 oncrete metal _FRP_other(explain)
Dimensions: 4,s`A
Sludge depth: �R
Distance from top of sludge to bottom of outlet tee or baffle: 1�
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 baffler
:r
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.) S ysT a oa ii e.,l Tv c t oN H a ga---pO 4 -&E
GREASE TRAP:_
(locate on site plan)
Depth below grade:
Material of construction: _conc a _metal _FRP—other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outle>teor ffle:
Distance from bottom of From to bottom ee battle:
Comments:
(recommendation for pumping, conditionnd tiet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
(revised 8/15/95) 6
; v
4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 1 teak S (-`p,1 T.,—v /1-- /Y/a,
Owner: /l, )q,
W, �/NrN1
Date of Inspection:
x-
TIGHT OR HOLDING.TANK:_
(locate on site plan)
Depth below grade:
Material of construction: _concret metal_FRP other(explain) /
Dimensions: %
Capacity: gallons
Design flow: gallons/day
Alarm level:
Comments:
(condition of inlet tee, condition of alarm and float swjtches, et
r,
'DISTRIBUTION BOX:_ K
(locate on site plan)
Depth of liquid level above outle:invert:
Comments:
(note if level and distribution is e , evidence of lids carryov, , evidence of leakage into or out of box, etc.)
PUMP CHAMBER:
(locate on site plan) ...._.
Pumps in working order:(yes or no)
Comments:
(note condition of pump chamber, condition of temps and appurtenances, etc.)
(revised 8/15/95) 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
�i SYSTEM INFORMATION (continued)
Property Address: �-04 jf ST CPv��I�'v�!l� Iva,
Owner: !l 77, E
Date of Inspection!// /'�' 941
SOIL ABSORPTION SYSTEM (SAS):
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type.
leaching pits, number:
leaching chambers, number:_
leaching galleries, number: .
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Comments: ( to condition of soil, signs of by rau ' failure, level of pond' g, co rtion of vegetation etc.)
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 o spectio
Comments: (note condition of soil, signs of hydrauli ailure,\1eof ponding, condition of vegetation, etc.)
PRIVY:_
(locate on site plan) -
Materials of construction: Dimensions:
Depth of solids:
Comments: (note conditio of soil, signs of hydraulic failure, level of ponding, condition f vegetation, etc.)
(revised 8/15/95) 8
r
0
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
r-SYSTEM INFORMATION (continued)
Property Address: Oa�< 5 t Ce -
Owner: R 13 Wr`�lr uv�+s
Date of Inspection:
96
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
C
i h
37Lrr G��e
3 30� 996,,
DEPTH TO GROUNDWATER
Depth to groundwater feet
method of determination or approximation: f,-h / oaw n by Tvk,yr Nl4/J,
(revised 6/15/95) 9
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
. ..........f06 .........OF...........jd.')-�.. ..............................—
.gyp lirtttiuit for 19iapaintl Wor1w Tondrurtinn frrinit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at:
..... ...a. ...... .......................................................
r Lot No.
...... .......................
------ . .... ... . .n.... ......
14 ;?� caner Address
.... ..... . ................... .......................... ...............................................0.................................................
. - 'iie
.1 .............insta r Address
Size feet
Type of Building Dwelling—No. of Bedrooms r .............................Expansion Attic ( ) Garbage Grinder ( )
No. of Persons...&.................... Showers Cafeteria ( )
Other—Type of Building
04 Other fixtures ...........................................................................................................
< Design Flow............................................gallons per person per day. Total daily flow...........................................gallons.
Septic Tank—Liquid capacity............gallons Length................Width................Diameter................Depth................
Disposal Trench—No.....................Width....................Total Length....................Total leaching area.....................sq.ft.
Seepage Pit No..................... Diameter.................... Depth below inlet....................Total leaching area..................sq, f t.
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........................
t% Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
............ ... .........................................................................................................................
0 Description of Soil... ...........................................................................................................
�4 . ..
U .............................................................................................. ........................................................................................................
........................................................................................................................ .. . ....er.
U Nature pA Repairs or Alter ionjr—A2aswer V(en�.aZplica I .................../.��.............
................
0:!........ ......:��. ....................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by lhe board 1 health.
, 0 .
Signed.. . .........I/ 7�
—
.......................
Date
Application Approved By.............. ................................ .......
D.te
Application Disapproved for the following reasons:..............................................................................................................
......................................................................................................................................................................................................
Date
Permit No....... n... ............... Issued_..7. .......
Date
............................ ..... ........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
&PAR..............................
...........OF............. -
(gerfifiratr of (Soutplitutre
THIS YL IS CER71FY That the Individual Sewage Disposal System constructed or Repaired..
by............ .... .................................................................................................................................
I twler
L..........C2 .1...r..1...........(.................................................................................................
at............ I...i1 i..i IP I I
has been installed in accordance with the provisions of TITLE 5 of Th State Sanitary Code as described in the
9 application for Disposal Works Construction Permit No........ ...? ........... dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE...................3*.... ....................... I Inspector............... ................ ——-----
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
No....�r.fr..... ... ............ .........OF............... ......................................
Permission is hereby granted..........CP........ e..........................................................................................
to Cditstruct or Repair (>� an Individual SeVe Disposal System
I .. .............................................................................
.. ........�.l..........at No........... C.".1. ...........
Street
as shown on the application for Disposal Works Construction P it N .... Dated..........................................
c Per o.
..................
i ..............
DATE................ .... .2. ...................................................
FORM 1255 A.M.SULKIN.INC..130STON
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