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HomeMy WebLinkAbout0038 CAPTAIN ALDEN'S LANE - Health 38 Captain Alden!S Ostervlli.e ; A = 146,=-091 I No. THE COMMONWEALTH OF MASSACHUSETTS FEE BOARD OF HEALTH OF APPLICATION FOR I)ISPOSA L SYYb,.d, M CONSTRUCTION PERMIT Application for a Permit to Construct ( ) Repair ( Upgrade ( n ( ) - [:]Complete System ❑Indidiviiddual Components p ocationlql Owner's Name `� I 'L� Address 0/�1A A 11 o # eft) a F � Telep e# /�� ste,�'s Na l/l� Designer's Name ddress ddre s Telephoril# TeleplIone# Type of Building: Lot Size Sq.feet Dwelling—No.of Bedrooms Garbage Grinder ( ) Other—Type of Building No.of persons Showers ( ), Cafeteria ( ) Other fixtures Design Flow( 'n.required) gpd Calculated design flow gpd Desi n provided pd Plan: Date Number of sheets Revision Date Title I 1 1, 11 Description of Soil(s) v Soil Evaluator Form No. Name of Soil Evaluator ate of Evaluatio I I , ( ) I t DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the above descr'Dec Individ al Sewage Disposal System in accordance_ with the provisions of TITLE S and fu�e m in o ratio Certificate of Compliance has bee issu by the Board of Health. Signed Date Inspections FORM t - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 I ` i� No. v v I THE COMMONWEALTH OF MASSACHUSETTS FEE I y "'BOARD OF HEALTH_ APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to 4-struct (, ) Repair '(� Upgrade ( Bandon ( ) - ❑Complete System ❑Individual Components Zation Owner's Name F Address l� WLIV4 <fO&AS G.y Teleph p { �pst er's Na Designer's Name Address ddre s .1 1'- y Telephone# Telep one# ' Type of Building: Lot Size Sq.feet Dwelling—No.of Bedrooms Garbage Griner ( ') Other—Type of Building No.of persons .Showers ( ), Cafeteria ( ) ; Other fixtures \ Design Flow(min.required) gpd Calculated design flow3 gpd Desi ri`fl w provide4!0!��Apd Plan: Date Number of sheets _ Revision Date Title Description of Soil(s) `• �,. Soil Evaluator Form No. Name of Soil Evaluator ate of Evaluatio014— DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and Zuagrees not ro p e th m in o ratio Certi$cate of Compliance has bee issue by the Board of Health. Signed Date 31 ; Inspections FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 __��....rNo...�--..,,.....—....�—..-- T — �MM .�.-.._�.—,..—.� — _........_,.._,v,�.m.�.... .�FEE..._�. ... 'r _ �-� ONWEALTH OF MASSACHUSETTS BOARD OF HEALTH CERTIFICATE OF CO IANCE Description of Work: ❑ Individual Component(s) W16omplete System The under ig)dnegd herebyOcertit: that the Sewage Disposal System;C nstructed( ),Repaired l5pgraded ,Abandoned( ) DjW at CI'.)^ I has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. dated *- —/ . Approved Design Flow / (gpd) Installer ' . 1 j Designer:.: Inspector 1 Date 7 The issuance of this certificate shall not be construed as a u rantee that the s stem will function as designed. FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96 _..,..-----_----d-- 3— -----_-.,---._, ----_— ..sue .-.,>.___,«___-:.._—.----,—......mob. No.1%1�_ 2�-�HE COMMONWEALTH OF MASSACHUSETTS FEE IBC/ BOARD OF HEALTH DISPOSAL SYSTEM CONS UCTIO ,PERMIT Permission is hereby ra ed to Construct ( ) Repair ( l- Upgrade ( Aba don ( ) an individual sewage disposal system at as de�c ' ed in the application for Disposal System Construction Permit No. A® dated Provided: Construction shall be completed within three years of the date of this permit. 11 local ti n: must Date r-1 �/.� Board of Health FORM 2 - DSCP DEP APPROVED FORM 5/96 FORM 1255 (REV 5/96) H&W HOBBS&WARREN TM PUBLISHERS-,BOSTON , TOWN OF BARNSTABLE LOCATION�4, O CAA OT L_D2,il)S `_I/ _ SEWAGE #ZO 0 QVILLAGEC ASSESSOR'S MAP& LOT 152* INSTALLER'S NAME&PHONE Nam`-7� � b�T° Za,/yl1 L C�bnST. SEPTIC TANK CAPACITY (avo q al li n LEACHING FACILITY: (type(Z4MA2caa(mr�C.Q.S (size)'?S v (`� NO. OF BEDROOMS BUILDER O OWNE PERMIT DATE: ZS �1 C� C 7 COMPLIANCE DATE: 6 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 2001feet.of leaching facility) Feet Edge of.Wetland and-Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 318" a l p:ac AR l� ` 3a �i' i Town of Barnstable _ Regulatory Services . Richard V. Scali,Interim Director • eMx.NsTAeM HAMPublic Health Division t679• Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-362-4644 Fax: 503-790-6304 Installer& Desigki,Certification Form Date: AV* 1�i 2017 Sewage Permit#Zo/7— 'E 7� Assessor's MapTarcei Designer: f 0WP Address: (SS GQO 9rd f 94 �00f� Address: 5--t-zj— IV c4of �gm; GPI 02633 e6_1(1111z1 /)-7 0 265:5' i p Y On O /6 / 7 � ��II��j L. n was issued a permit to install it (date) (installer) septic system at M 'Cipt'• Woo 'duke' based on a design drawn by 4�i 1 (address) �vid • 'Co Rawr �t.5 dated 1� � . ; 20117 j (designer) V I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Strip out (it' required) was inspected and the soils were found satisfactory. EXtSTWG "SEPT" C 74NK WAS oFOU M D TO 13E TN GooD COWD1 TI OW gF JZCUSED certify that the septic;system referenced above was installed with major clianges (i.e. greater than 10' lateral relocation of.the SAS or any vertical relocation of any component of the septic system) bui in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. Strip out (if required)was inspected and the soils were found satisfactory,: I certil' that the system» referenced above was constructed ' e'with the terms of the approval letters(if applicable) o` .DAVID, ��, D: + COUGHAN6Wt2 (ld9taller's Signature) Na. t Q93. STE S s'4NI TAR% (Designer's Signature) - (Affix Designers Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CER`i`IFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS: BUILT CARD ARE RECEIVED BY THE BARNS"TABLE PUBLIC HEALTH DIVISION. THANK YOU. 11 Q&pticTcsigner Ccniticntion Fomi R'v 5-14-13.doc SEPTIC F® T LEGEND ®o u SEPTIC COMPONENTS EC EXISTING 1600 GAL SEPTIC TANK • INSTALL .NEW 1500 GAL. O' - ' SEPTIC TANK • r O VEME EXISTING Of fi GE LEACH PIT./ Do1�1 EO 59 CESSPOOL Op ft; DISTRIBUTION BOX 00 D :• `U ,030 T 4 TEST PIT' 60 00 AREA. = 15060 sf+— PLAN BOOK .d t ZS'PAGE \ PROPOSED SOI LL ABSORPTION ASSRM ,46 CL 91 SYSTEM. L.b 0. ti\ C,l -SEE DETAIL ON:BACK O IB ' z 0 INn_ \ THIS IS A y - •IB In p \ tr •s O PINE y, \ a COLOR �. PLAN ' USE COLOR PLAN ONLY \ \ A FOR INSTALLATION MINIMAL: FULL DETAIL 1S BEST 9 _ 'GRADING G P VIEWED, IN PROPOSED FULL COLOR ti \ 57 60 ;TONG B20 EDR001, OF ��®� PINE n . TOG ft EL m 20 in PINE A. 15 in SCREEN fr 12•in OAK PORCH PINE 12 ft /12 in OAK oar. ® " 0 .5 9 -2 0 IMLA nn 12 in 12 1n /I OAK. OAK i tpgLE yGIS Glj \ oai: p0 epQN T' A!!!y ` ELEVATION 58. 92 �.� s� . Spor ON BULKN 0�;Et GAR �0S• R - OT .` �.i OWED 58 NOTES ;� �k�G�LANI REMOVE 12: INCH :WHITE PINE WHOSE .GIP kK. SC:ALE: l '.in 20 ft ���� ����� `. ROOTS HAVE THE, EXISTING 1000 GALLON SEPTIC TANK IN A .DEATH . � � 0 20 4� PUMP ANO REMOVE EXISTING. 1000 WATER LINE.��' GALLON. SEPTIC. TANK AND REPLACE �C�� D• 10 20 'OVERHEAD-WIRE. OH WITH A NEW- 1500 GALLON:SEPTIC TANK: r PRINT ON `8=1/2 .x 14 in OL Y-el PAPER , FOR . PROPER S.CAL:E NOT SCALE SNOFMASs9�. P�S'Aw44ASS9 .�✓, �ti :S.EWAGE DISPOSAL P��G QAVID yGJ,. off'`` DAviD ' �y� SYSTEM PLAN LOCUS < D.. �`, D., .. r -TO SERVE EXISTING DWELLING a$i <+. COUGHANOWR H COUGHANOWR D A V I D M. v '}' No. 1093 No. 461 v i SLATER 0 FALMOUTH ROAD-RT 28 ,p p �' �ti� �� � � 'OWNER(S) OF RECORD qG1 Soi9pR0Uo ° 38 CAPTAIN ALDENS LN. r OSTERVILLE, MA m 155GeoRdetRdS PROPERTY yADDRESS OSTERVILLE. MA THIS PLANIS INTENDED SOLELY FOR INSTALLATION OF THE SEPTIC SYSTEM Chatham. MA 02633 - C DEPICTED ON Il'.FOR ANY OTHER CHANGES TO THE PROPERTY INCLUDING Davidcou(§H^otmoiLc(omm DATE: MAY 20, 2017 PLACEMENT OF L O MAP SHOULD CONSULT WITH ADDITIONS.MA SACHUSETTSSHEDS.FENCES OREGIS EREDGIANDOSURVOEYORp SOH 3 V`Y O H 7`? PG l I Z JOBa E?E-416 6 q CON --..8. - - �' S01Lo. 0 LOG PDATEt MAY E C# 53385. 2017 .EVON C A LCULAW O NS SOIL EVALUATOR: DAVID D. COUGHANOWR, ASE #461 DESIGN FLOW: 3 BEDROOMS X 110 GPD = 330 GPD WITNESSED BY; DONALD DESMARAIS, HEALTH DEPT. -f EST FAT 1 P RCOT 50 in AT2RM ENCOUNTERED N NOH INECESOILS REMOVE EXISTING G 00 GALLON SEPTIC TANK ELEVATION.DEPTH SOIL USDA.SOIL SOIL COLOR SOIL OTHER AND STRANGULATING WHITE PINE. INSTALL INCHES. HORIZON .TEXTURE (MUNSELU ' MOTTLES: - If NEW 1500 GALLON SEPTIC TANK. 57'.15. 0-4 O WOOD. LOAM '10 YR 212 NONE FRIABLE DISTRIBUTION BOX. INSTALL UNIT -DEPICTED,BELOW. G 4-6 E SANDY LOAM 10,YR.3I1 NONE FRIABLE 6712 A LOAMY SAND .10 YR'4/6' NONE FRIABLE SOIL ABSORBTION SYSTEM: 12- B LOAMY AN 2B. SAND 10 YR 5/6 -NONE LOOSE THE LONG .TERM ACCEPTANCE RATE.FOR A CLASS,ON L S E 28-138 C MEDIUM SAND 10.1R 5/4 NONE LOOSE SOIL"' WITH A'PERCOLATION RATE BELOW 5 MINUTES 45.65 PER INCH 0.74 GALLONS PER,DAY PER SQUARE. FOOT. NO GROUNDWATER-ENCOUNTERED. -TEST TIT 2 2 MIN/iNCH IN C SOILS THE 24 ft x 12.5 ft x 2 fvLEACHING GALLERY DEPICTED' BELOW CAN 'LEACH:. 'ELEVATION DEPTH .SOIL USDA SOIL SOIL COLOR :SOIL' OTHER - INCHES HORIZON TEXTURE. (MUNSELU) MOTTLES BOTTOM' AREA - (2.4 X.12.5) - - = 300'•SZl, .f t, . 56.90 0-4 O- �WObD LOAM '10 YR 212 NONE, FRIABLE S►DEWAL•L AREA _ (24+24+12.5+12.5)x2 =146 so. ft. 4-6' E SANDY.LOAM 10 YR.311 NONE FRIABLE A LOAMY SAND 10 YR 4/6. NONE FRIABLE' TOTAL AREA.= 446 sq. ft. 54.73 . 10-26 18 LOAMY SAND 10 YR 5/6 -NONE. LOOSE.", FLOW 'CAPACITY 0.74 x 446 =.330.04 9Ol/day: 45.40 26-138 • C MEDIUM SAND' 10 YR 5/4 NONE LOOSE INSTALL A 24 ft x 12.5 ft x 2 ft GALLERY AS CONFIGURED BELOW. FLOW.CAPACITY = 330.04 gal/dog WHICH EXCEEDS :THE 330 gal/dog REQUIRED FOR A THREE BEDROOM DESIGN. �500 G�1 LL°Ol�l. SEPTI T • I�IK - - - 0 © c o s "gym DIL =A = S'OR'rTl o0N o® I in NOT m� •• o TO 'DRYW ELL 'TAPER ® 24:0 ft SCALE cn UNIT. Q 8 lnt In � 0 c) N 4 l ` cp :S TONE ONE^ 13:5 ft 8.5 ft 8.5 ft 3.5.ft ft-6 500 GALLON. DRYWEL.L I DIMENSIONS & DETAIL INSTALL ONE INSPECTION INLET OUTLET COVER COVER ' " RISER TO WITHIN THREE USE INCHES OF FINAL'GRADE. M-)0 & INDICATE LOCATION 3 IN DROP ON AS-BUILT. -► FLOW LINE. UNIT - ai r •.. FROM - -►. y: j ;. 33 BUILDING , IO in _ 14 TO _ Q� .m D-BOX 1 in ' 48 in fir + I k LIQUID GAS DDT \n LEVEL BAFFLE 5$ .10210 n b In STONE easE - CROSS.:SECTION VIEW SEPARATION BETWEEN INLET. & OUTLET' INSTALL AN APPROVED GEOTEXTILE TEES NO LESS THAN LIQUID DEPTH, FABRIC OVER STONE' CROSS SECTION VIEW , DI TRI = UTION 28 e� 3 -_ 3/a m i ro � 24 in a -r--3�:�In O .: ► 11/2 In GRAVELI� EFFECTIVEN I ►12 /n GRAVELx- ► , ► • ► B• • in ,� >3=x e DEPTH' AN 'S a ET AIL FOR 2 FEET BEFORE PITCHING DOWN 46 in 58•in 46 in . - '150"in 12 In •c MIN . -INSTALLER TO OBTAIN DISPOSAL WORKS PERMIT BEFORE' -► N STARTING WORK. FROM 5 —� -ALL COMPONENTS INSTALLED SHALL MEET THE MINIMUM N'" TANK �TAO REQUIREMENTS OF MASSACHUSETTS TITLES SEPTIC P S :CODE (310'CMR 15). Q INSTALLER TO VERIFY. LOCATIONS OF ALL UNDERGROUND x T UTILITIES BEFORE EXCAVATING FOR SYSTEM. ECO-TECH.ENVIRONMENTAL RECOMMENDS 'THE INSTALLATION \( 6-In STONE BASE Q OF'LOW. FLOW FIXTURES 8 APPLIANCES, AND PERIODIC " PUMPING-OF THE SEPTIC TANK. 2/ jj� 21 CROSS SECTION VIEW S -SYSTEM,IS.NOT DESIGNED TO WITHSTAND VEHICULAR LOADING. DO NOT PARK OR DRIVE VEHICLES OVER SEPTIC 'SYSTEM. j TOP OF FOUNDATION RAISE COVERS `TO 1N1'THIN ALL..PIPE TO. BE 4 in SCH: 40:PVC EL 59.51 +— 6 in..OF FINAL GRADE-7AND TO PITCH AT I/8• in/fC MIN 5;9.0 57.0 D�B® 3' u USE H=20 M A X ���7GH,1�� .55:25 - 57.50+ ���� ALLPRECAST �� ;,•� e EXISTING." • a o0 o° e �C�P�LO TANK . 56.75 �:o ' DRYWELL 54.68 � bin � i 57.00 'REFER . TO DETAIL BOX 54.85 STONE SM ABSORPT�QN + a /n: rowe. ease BASE '54.50 SYSTC�Mli -REFER TO 10 .ft bl ft 5-12 ft DETAIL BOX U) U' NO GROUNDWATER BELOW j 52.50 MOTTLING OBSERVED 45.40 j I S ALDENS LANE OSTE- - - - - - - ; SEWAGE DISPOSAL SYTEM PLAN; 38 CAPTAIN _ - RVILLE, 'MA rMAY 20, 201= ETE-4166_:RG 2I2' 15�5 Date Scheduled - �� !� y_ . T!'tne Toe Pd.' Soil Suitability Assessment for Se L DIsposrxl ; ''l, `` . Performcd•Ily: D.,v I G l u . C°I J�•I�)?C vYC Wltnrasad 8y. LOCATION&,GENERAL Wj ORMATION Location Address Owiees NameLL 0S Addres,. Assessor',Map/Parc# (4 6f 1 t� i . n t e r v,1' Bnginece Name k,, t" �(�j6kf�tl w, NEW CONMUMON REPAIR . y Tela hone tf .S Slopea(96) 0 Land I SuOIZ rtilca Stonas Distances firm: Open Water Body Possible WotAreo �� � f t Drinking water Weu l�G�.f Drelhngo Way. r R Proparly Llne - ( � 1 n Other' 1 1t SKETCH:(Street name,dimensions of lot,'c.actlocstlons of test hulas& era tests locate I " . . P /„ wetlands in proximity to holm). r Al 1 i k TP:?. - Parent material(geWent )-�f t�G�.� dL'i vvg5l) Depth to 110tlmok " 1 ��1T� i �- j Depth to Oroundwatec Standing Water In Holo 0 Vi �': Weeping ftom P1t Fn4a V) 17- f VY��`�e fi h`►11 13r6 t n I3stlmatcrl Seasonal High OroundwOter __ �TION FOR SEASONAL`HIGI WATUR TABL_ (. Method Used: Dc th Observed standing In obs:hole: Ia; Depth to aoll,tnottlesrt d pm,-�i.t. i 3g In;' Dollth to waopinh from dda of dbs.liolai In, tlroundwater AdjusltAant 1 4 fi. btdoz Walldl Reeding VAIG; .1 Index Well IoYol,�_ ;, -ArjAclor Atj;Or jundwatep•LaVel I '-PERCOLATION TIMST pain 1 �CIIile �� M ObsoNaflmi Flalo lL (• •+ 'Clniti at Dopilr of Palo _�= Tlmo at 61' S16t Pro•soakTimo 9 �� .G�G� ; 'limo(9"•b") " lh 1 End l'ro-,nak `3 r 4 P Rota Mlh.Moh (( ZtM1 ,I {. nb-n..1•_,_IIL_.•�____,_._L'._ n4�1�___L•J i� I/ q11�n_II�.1. �1 •�JL1__tl rw__a__�1_._.1_�Ivor• � i L '1— LX-rim -)117/1 IUIJI ' t= I I'myte . 1`L-28 s�� 4S G Mel t Ji�ta�i>I tooK L�5 La DEEP OBSERVATION HOLE LOG Hole# Z Depth IV= Soil Hotlzon Sall Texture Soli Color Sall Other Surface(ItL) -(USDA) (Munsellj Mottiing (Structure,Stmej,Boulders. eta.76 Oravalr)_ 3/t Im Le- 13 1 ;ern Sh ��� �, Lv0s e. DEW,POBSERVATION HOLE LOG Solo Depthlbm. Sall Horizon Soil Texture . Sall Color. Soil buffer Surface(lu.) (USDA) (Muntdll) Mottling (Structure,Stones,Douldan., lnthaSly.9L.grnvell DEEP OBSERVATION HOLE LOG. _ Hole# Depth from Sall Horizon Soil Texture Soli Color. Soil Other Surface(in.) (U$DA) (Mumall) M4tiing (91ructure,Sitcom Boulders, food Inartrnnce Rate MaR Above 500 year f lood boundary No_ . Yee Within 500 year boundary No r Yet Within l00yehr flood boundary Na,� Yes,,,. Beath of Nu rally©ccurrina Pet:vloue Material Doos at toast four foot of naturally occurring pery ue olitot`lal axlet in all areas observed thrpughout the area proposed for the soil absorption sylitem? If not,what is the depth of naturally occurring pervious material? �. er"t ilcagon I cortlt}►that on (da(e)T have passed the seta evaluator examination approved by the and'that the above analysis was performed by me conslstant with Department of Bnvironmental Protection Il the rcqulre4,trainingj iportlee and oxporyottc e� od in 410 CMIt 15.017: �l ` LOCATION SEWAGE PERMIT NO. - � VILLAGE INSTA LLER,'S NACRE ! ADDRESS R U I L D E R.-0 Owcaa DATE PERMIT ISSUED 7 DATE COMPLIANCE _ISSUED /� � {...,..� ....a: -.3 v`�P �� � �-- � " No.-...� ... F .............. THE BOARD�OF HEALTH TS (p r .-__-.l 0.40.M...............OF.....3ARIV.S.7A-0.6.4_................................ Applira#ilan for Bispoii al nrkii Tonstrnrtinn rrmit r _ Application is hereby made for a Permit to Construct ( �or Repair ( ) an Individual,Sewage Disposal System at: ...............................r................................ Location-Address or Lot No. ................................ .....................................•-•-•- Owner -- ---••---•--------•Address Installer Address Type of Building Size LotIS _�,..............Sq. feet Dwelling—No. of Bedrooms_______.___ ________________________Expansion Attic ('vo). Garbage Grinder (Nea `4 Other—Type of BuildingNo. of persons____________________________ Showers — Cafeteria 04 Other fixtures _____________________________________ ---=--------------------- �_----------------•-----------••-------------•------------ w Design Flow........ /0....................... per perlay. Total daily flow_.__._._.____ 3_�?__._._...._.___gallons. WSeptic Tank—Liquid capac>tyQAW__gallons Lengthc9_._"e__ :. Width.Z_lV_ _ Diameter________________ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No....../--__-______ Diameter.._. ...... Depth below inlet...... ...... Total leaching a aj5Z-;20..sq. ft. Z Other Distribution box Dosing tank Percolation Test Results Performed by.kc)AL 44PA__.&t... _.__ Date...AIdG___...... Test Pit No. L_e_A-__minutes per inch Depth of Test Pit-Z:�-_/....... Depth to ground water._?J4A2 Aff-",__. Test Pit No. 2................minutes per inch Depth of Test Pit..............._.... Depth to ground water........................ --------------------------------•_-__--_...::---....-:-•---------------........______....-••••------- -_.....__------•------ . " ® Description of Soil.....C1-- ...-"�.....�,.�.l�ed - ...... ------- - x U .---------------•-•••-----••-----•••••----•-•-•-•-••-•••-•-••-•-----••••-••--•-•••••---•---...--••-----•-•-------------•---------•••••-----•-----.....--••--•••--•--•-...........•---•-------•••--••••--- w U Nature of Repairs or Alterations—Answer when applicable............................................................................................... .............. Agreement: The undersigned agrees to -install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of LITLE 5 of the State Sanitary Code—The undersigned further,agrees not to place the system in a operation until a Certificate of Compliance has been • ued by thg board of health. Signe .......................... ................................ Date Application Approved BY.........----- /------ ----------------------- .1...�: r-` Date Application Disapproved for the following reasons________________•___.....______________________________••_______-____________.__...____.___._____________________ ---------------------=------•----------..._..------------------------•---•------._......_...-------•--•-••••••-•••••-•••••--•---•---•-••-•-----•-•-•---------......................................... Date - 7 Permit No.---•----•---•- -- Issued.----:.�....-�� '-----•- •-.......a�--•--- Date - -- L' �. THE COMMONWEALTH 0Z MASSACHUSETTS BOARD OF HEALTH Gt,i.IV.............. OF.... l N: ., .�+ .C� ................................ Apli irFatiun f lar Dispaii al Works Tomitrurtitun ramit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: C 4�'�• Zt I 1 ........... -7'eZ?I1L.. ... ..... ' .................................................. ...... ............ 16 °, Location-Address �a §No 7 ..... ........---•......................... ..._ �/Q :_ ................................... Owner Address .... ........... .f-•-••-••-•-------••••--•-------•-•-----------•--•----•- --...••--•-•-•••••-••-•--•-•••---_............•___.....-___...._.....:......-•-••--•---......-•-- Installer Address Type of Building Size Lod$ .4150........Sq. feet Dwelling—No. of Bedrooms.............. .........................Expansion Attic '(N®) Garbage Grinder (Nta Pk Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) d Other fixtures ------------------•-•--•:------- •-• - - W Design Flpw.......././.........................gallons per n per ay. Total daily flow....... ._.. .3�.0 ........gallons. R: - Septic Tank—Liquid capacity/.&&P__gallons Length_ `"._ Width.'V &`** Diameter................ Depth_0-F_W..�f W Disposal Trench—No_____________________ Width.................... Total Length................... Total leaching area_...................sq. ft. Seepage Pit No...... Diameter..__ ,�. ....__._._ x Depth below inlet..... ......... Total leaching areal:Q0._sq. ft. _ Z Other Distribution box Dosing tank ( ) '-' Percolation Test Results Performed ... Date..44k!s ZfJ18 •. a a Test Pit No. 1.4.z-_...minutes per inch Depth of Test Pit eA ....... Depth to ground water Aj,* .4& -__. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ W ••--- . ---•--•-----•----•--•------•............... ...__....... -•............O Description of Soil..... sZ...._e,4.. ,41...._4,4/p•----.5al 064.--.....42.= , !'t/ ----54 cxj •-•-••-•••--••---••••--...-•-•----------•-•--•-••-•....••••••--••••••-••-•.........-•-------•-•••-•-•------•••••--••-••--•--------•-•••-••••-•-••-•-••._......•••...............••---•-•-----••-•-....._ W U Nature of Repairs or Alterations=Answer when applicable...............................:...................................................:........... ----.....-•--------------------•-----------------•--------------------------•---------------....-----.....----------------------......------------•----•--------------------------•-•---.._.......... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of 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 the board of health. Sikfie -------------------- Date f Application Approved By...... .. / ......................................................... E1.........�2, :_7 Date 1-- - Application Disapproved for the following reasons --------------•--•-------------------•---••-------------------....---------•••--•-•-•--•-.......-- : Date w k PermitNo................•----......._............................ Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOA OF HEALTH .......:.......:0 f......1 ":...................... �rrtgf�rtttle of �um�li�an�'r TH,�S TO RTIFY, That the Individual Sewage Disposal System constructed (40) or Repaired ( ) Installer at..... �•�'�-----•. � '� . '' ,r "!"'~ _.va.4c--------------------------------------•-...- has been installed in accordance with the provisions of T r of The State Sanitary Code as described in the application for Disposal Works Construction Permit �, :_ _._ _ ,. ............. dated_(.__-'_`/,tr...7f............... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE. .................... :'Inspector....:..............................•--------•----••-----.._..-•-•-•----•----••_.._.. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH < / ..r!� ............OF....../; -: ................... li N...:...... .......... FEE._.... ............. ku ntrtuan rrmit Permission is ereby granted ({✓Iae=._... ............................. to ConstructE Repair ( ) an Individual Sewage Dispos System at No.••--L.p'`........� e�' b-44,_AZ---::4JAV_4.........52s..!-Ise.--W.Ce... '.......-•-•-•-•---•-------•-•-------••. Street as shown on the application for Disposal Works Construction Permit ........................... •DATE................................................................................ Board of Health FORM 1255 HOBBS & WARREN. INC., PUBLISHERS , P°A.UL. •/V U A,y- : N S RCCT-OR j. 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