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HomeMy WebLinkAbout0187 EBENEZER ROAD - Health 187 EBENEZER ROAD, OSTERVILLE A= 0 v TOWN OF BARNS AB E � LOCATION A YAZZ.�2G- SEWAGE # 1�7- VILLAGE L/���'yl�l � ASSESSOZ!! MAP&LOT I b d 74- � SEPTIC TANK CAPACITY LEACHING FACILITY: (type) 6 j (size) �d NO.OF BEDROOMS BUILDER OR OWNER V /•� PERMITDATE: �(�, 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 fe�f leachin f ili Feet Furnished L ," Frew i 0 100® ^c4 '*2 PROPERTY ADDRESS: ;1.87 -Ebenezer Road IRECEOVED Osterville ,Mass . 'J U N .7 1996 0 2 6 5 5 WALTH DEPT. TWN OF BARNSTABLE On the above date, I inspepted the septic system at the above address. This system consists of the following: 1 . 1-1000 'gallon septic tank. 2. 1-Distribution box. 3 . 1-1000 gallon leaching pit. eased bn my Ins.nection, I certify the following conditions: 1 . This is a title five septic sy's e•m. . (, 7.8' Code ) 2. The septic system is in proper working • order-at the present time . 81GNATUR�: G %( Name:_J_P._M'acomber J_r•.___---_ ,7.P.Macomber & Son- *Inc .. , Company:------------=------- .r Address:__B.0_x_b6-------1------- Ce 0.2.632 ` Phone:---5a8-77-5-333a------- ., 1 THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY ,pOSEPH P. MACOMBER & SON, INC. Tanks-CesuP M Leszhfleld: . Pumped & Instsiled Town Sewer Connection: P.O. Box 66' Centerville, MA 02632-0066 77.5-3338 775-6412 t Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection William F.Weld Trudy Coxe t3owmo. 6-1 9-Y Argo Paul Celluccl David B.Struhs LL Gowmor Commbslorw • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION ProportyAddroa,: 187 Ebenezer Road Osterville ,Mass AddreasofOwner. Date of Inspeotlon:5/29/96 (If different) Namcofln,peotor.JoSeph P. Macomber Jr. Company Name,Address and Telephone Number. J.P.Macomber & Son Inc. Box 66 Centbrville ,Mass . 02632 508-775-3338 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: Zpa"es — Conditionally Passes — Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: �f %/! `�� �� Date: �' J The System Inspecto ks 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: 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 indicawd 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, 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, clacked, structurally unsound, shows substantial infiltration or exilltration,.or tank failure is imminent. The system will pas, inspection if the existing septic tank is replaced with a ponforming septic tank as approved by the Board of Health. (revised 11/03/95) 1 One Winter Street a Boston, Massachusetts 02108 • FAX(617) 5545-1049 • Telephone(617)292.SWO �� Printed on Rtc cled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) PropertyAddresa: 187 Ebenezer Road Osterville ,Mass . Owner. Roy Jones Date of Inspection: 5/2 9/9 6 Bl SYSTEM CONDITIONALLY PASSES(continued) AD Sewage backup or breakout or high static water level observed is the distn tion boat is due to broken or obstructed pipes) or due to a broken,settled or uneven distribution bout. The system will pass inspection 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 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 Cl 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 the Public health,safety and the environment. faulung protect 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 ENVIRONMENJ,- Ald Cesspool or P� 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 PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for ooliform bacteria and volatile organic compounds indicates that the well from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than is free ppm. 3) OTHER (revised 11/03/95) 2 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (oontinued) PropertyAddre,,: 187 Ebenezer Road Osterville ,Mass . owner. Roy Jones Date of Inspeotion:5/29/9 6 D) SYSTEM FAILS: • /mod 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 necessary to correct the failure. Backup of sewage into facility w,system component due to an overloaded or clogged SAS or cesspool. Ab 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 tb a distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. kPa4d, Pir Liquid depth in seespool 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. A& Any portion of a cesspool or priAy in within 100 feet of a surface water supply or tributary to a surface water supply. _!Vfl Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or pri-,y 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. El LARGE SYSTEM FAILS: The following criteria apply to large sysu�nw in addition to the criteria above: v v The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 11,Lry 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 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 Anther information.. (revised 11/03/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST PropertyAddres. 187 Ebenezer Road Osterville ,Mass . Owner. Roy Jones Date of Inspewtion: 5/2 9/9 6 Check if the following have been done: _K�umping 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. ZAs 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. 2The system does not receive non-sanitary or industrial waste flow The site was inspected for signs of breakout. JAIL system components,Iffreluding t):e 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 existing information or app ted by non-intrusive methods. facility owner(and oocupants, if'different from owner) were provided with information on the proper maintenance of Sub. Surface Disposal System. (revised 11/03/95) 4 SUBSURFACE,SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 187 Ebenezer Road Osterville ,Mass . Owner. Roy Jones Date of Inspection: 5/29/96 RESIDENTIAL- FLOC'CONDITIONS Design flow: ons;oer d' s Number of bedrooms: Number of current residents:. Garbage grinder(yes or ao)13 Laundry connected to s m(yes or no):,��i Seasonal use(yes or no Water meter readings, if available: / /! = Q' 1 Last date of occupancy:-i�-1,0 COMMERCIAL/INDUSTRIAL: Type of establisrent: fi) Design flow: gallons/day Grease trap present: (yes or no)—w Industrial Waste Holding Tank present: (yes or no)-&9 Non-sanitary waste discharged to the Title 5 system: (yes or no)" Water meter readings, if available:__ nl Last date of occupancy: OTHER (Describe) Last date of occupancy: GENERAL, INFORMATION PUMPING RECORDS an soyof information: t System Pumped as past of instton: (yes or no) If yes, volume pumped: �`0 oils Reason for pumping —_� ( 1y11` ����` l `l et✓y s TYPE 30W SYSTEM L SePtic tank/distribution box/soil absorption s}rtein Single cesspool Overflow cesspool Privy Sbared system(yes or no) (if yes, attach previous inspection records, if any) 0 ) Other(explain) APPROXIMATE AGE of all components, date ulstalled (if known) and source of information: Sewage odors detected when arriving at the site: dyes or no) (revised 11/03/95) fi SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C. SYSTEM INFORMATION (continued) Property Address: 187 Ebenezer Road Osterville ,Mass . Owner: Roy Jones Date of Inspection:5/29/96 SEPTIC TANK: I r`wo gnIJ44% T41VK- (locate on site plan) Depth below grade: Material of construction: concrete _metal _FRP _other(explain) Dimensions: ,C Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle:__ Scum thickness:_ Distance_from top of scum to top of outlet tee or baffle: Q Distance from bottom of scum to bottom of outlet tee or baffle._ .a Comments: (recommendation for pumping, condition of inlet and outlet tees or baffle. de th of liquid level in relation to outlet 'nv integrity, evidence of leakage, etc.) Pump tank_ .annually a� r%age �dis.posal pre sen�•�n �"-r i outlet #yes axe„in place;Tank is structural No s.in,9 o ea cage . TTn gaga.•�,•Q needed at the present1 T �'—' —r-- z .. GREASE TRAP./(/p41e (locate on site p+an) Depth below grade:;Ide Material of constri.lrii6n;Ai��Q}}:oncrete _metal _FRP —other(explain) Dimensions; i�_� 1if Scum thickness: Distance from top u', scum to top of outlet tee or baffle: A,+l) Distance from bottom n+ prom in bottom of outlet tee or bahte:_ Comments: (recommendation for pumping, condi—ri of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,fe�`vidence of leakage, etc.i_ JG s6 y, (revised 8/15/95) 6 `°ProPertyAddress: 187 Ebenezer Road Osterville,Mass . Owner. Roy Jones Date of Iaspeotlon:5/2 9/9 6 TIGHT OR HOLDING TANK;&6,4 e— (locate on site plan) Depth below grader Material of consttnuction/gooncrete_metal_FRP—other(explain) IV 19 Dimensions: A/19 Capacity: /11 A Gallons Design flow: allona/day Alarm level:_H ' Comments: (condition/of inlet tee,condition of alarm and float switches, etc.) 111 6 C��s1�I vYl .U7 S DISTRIBUTION BOX:Z (locate on site plan) Depth of liquid level above outlet invert: .10 Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) Did not dig up box cover. 3 . 5 ' below grade and under garden timbers. ran water from the outlet end of tank to the box. Water flowed freely to the 1pgohinn nit PUMP CHAMBF.R:A/-0,V e, (locate on site plan) Pumps in working order:(yes or no) A14 Comments: (note condition of pump chamber, condition of pLunps and appurtenances, etc.) (revised 11/03/95) 7 SUBSURFACE SEWAGE IIISI'OSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (oontinuod) PvopottyAddroaa: 187 Ebenezer Road Osterville ,Mass . Owner. Roy Jones Dato of Inipootiou:5/29/96 SOLL ABSORPTION SYSTEM (SAS):J (locate on sits plan, if possible;excavation not rvquir-od, but ntay be upproximated by non intrusive methods) If not determined to be prosent, -Plain: Type: leaching pits, number: leaching chambers, number leaching galleries, number. leaching trenches, number,length: leaching fields, number, dimensions: __ overflow cesspool, number:, Comments: o pondition of soil, sigi- of hydulic failure, level of ponding, condition of vegetation etc.) Or UOnding; S61s l�e�>_ rnum sand to fine sand.No signs__nf 'hydra„i ct f al-1;.. aII vege a ion is norm CESSPOOLS:/J (locate on site plan) Number and configur — Depth-top of liquid t invort: Depth of solids layer _— Depth of scum layer:! 1U ------ Dimensions of cesspool: Materials of construction: —_----- Indication of groundwater: inflow(cesspool must be pumped as part of inspection) Comments: (n condition �+of soil s' of hydraulic failure, level of ponding, condition of vegetation, etc.) �lC (.OH'lil�PildY� PRIVY: �piG•{, (locate on site plan) Materials of constr•u n: /�� Dimensions:_ Al� Depth of solids: i Co nts_ (note condition of soil, signs of hydraulic failure, level of goading, condition of vegetation, etc.) (revised 11/03/95) b SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (oontinued) PropertyAddresa: 187 Ebenezer Road Osterville ,Mass . Owner. Roy Jones Date of Inspection:5/2 9/9 6 SKETCH OF SEWAGE DISPOSAL SYSTEM: ' include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' Centerville Osterville Marstons Mills Water Company -- _ - - 428-669-1 I DEPTH TO GROUNDWATER Depth to groundwater. 14 1 +feet method of determination or approximation: No water encountered at 121 when system was installed. Plan nn filA qt the Barnstable Board Of Health. (revised 11/03/95) 8 1� . .-•try-. SIB . - �� W Y TI�3CE COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION BE IT KNOWN THAT Joseph P. Macomber, Jr. Has satisfied the Department's qualifications as required and is hereby authorized to use the title CERTIFIED TITLE 5 SYSTEM INSPECTOR as provided in 310 CMR 15 .340 and Section 13 of Chapter 21A of the General Laws. Issued by The Department of Environmental Protection. June 8, 1995 Acting Director of the ion of Water Pollution Control IJ ,i,owN OF Barnstable BOARD OF HEALTH INSPECTION FORM PART D .-- CERTIFICATION SUBHUFAU SFWAGE DISPOSAL SYST�,M -TYPE OR PRINT CLEARLY- PROPERTY INSPECTED STREET ADDRESS 187 Ebenezer Road Osterville,Mass . ASSESSORS MAP , DLOCK AND PARCEL # OWNER' s NAME Roy Jones PART D - CERTIFICATION NAME OF INSPECTOR -Joseph P.Macomber Jr. COMPANY NAME J.P.Macomber & Son Inc COMPANY ADDRESS Box 66 Centerville ,Mass . 02632 Street Town or City State LIP COMPANY TELEPHONE ( 508 f 73_�_ - 3338 FAX ( 508 790 1578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate , and complete as of the tj.tn* e of .-inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one : XXXY,XX—XX System PASSED The inspection t4hich I have conducted has not found any information which indicates that the system fails to adequately Protect public health or the envirotiment, as defined in 310 CHR 15 , 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . System FAILED The inspection wilicl, I have conducted has found that the system fails to protect the public health and the environment in accordance with Title 5 , 31O CHR 15 . 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form , Inspector Date 5/31 /96 One copy of this certification must be provided to the OWNER, the BUYER ( where applicable ) and the 130ARD OF HEAL'I'll. If the inspection FAILED , th-e owner or operator shall upgrade the ayatem within one year of the date of the inspection , unless allowed or requirc.(j otherwise as Provided in 310 CHR 15 . 305 , -07 _ w 1 No.-- --... ... F:m$.........J!. THE COMMONWEALTH OF MASSACHUSETTS [c14 BOARD OF HE LTH 1'4(-o ........OF..... .. . .. ApplirFation for Diiipos ai Works Tnnitrnrtion ramit Application is hereby 'made for a Permit to Construct �o R pair ( ) an Individual Sewage Disposal S t at. .... . ..._ .... ............ . . ........... ..................... ................---•-----.._. .............--.-•--- .._--•••--•-----------•-------...__.__----.. v Locati0 Address or Lot o. ........ ............ ................. .......................................---•--.............................. W _...... -. _ — /A_ddress a ...............:...:.'—•••••••.--'.... ::. {' -----..eYF .-----....---------............................... 'Y� Installer Address Q Type of Building Size Lot... feet Dwelling—No. of Bedrooms....... _...............................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons................ ----- Showers — Cafeteria Otherfixtures ...... `' °- "---------------------------•------------------------------------------------•------------------------------•-----._----- w Design Flow.... 0...............:...............gallons per person per day. Total daily flow..............2. ................gallons. WSeptic Tank—Liquid capacity A® allons Length................ Width.............:.. Diameter................ Depth................ x Disposal Trench—No. .................. Ttotal Length.................... otal;leaching area....................sq. ft. Width � � Seepage Pit No.... Di ^_........... lPinl __________ ______ o a eaching area.................. ft. Z Other Distribution box ( ) Dosing.ta ( —�S 7 Percolation Test Results Performed by.._ .. _. ..`....._ _..! o??}_ .S...... Date......................................... Test Pit No. 1....4/.Z....minutes per inch Dept of Test Pit____________________ Depth to ground water....................... 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ O �� 3 �S,r.� -- .......... ----- -- /2 �lZC J� Description of Soil.... ---- •---- ....._..�4 ... N-!r � ........ ' x w UNature of Repairs or Alterations-Answer when applicable____-_----.-•______________•__--__-------.---------__-_-I......................._.............. .............................................................----------•-.....-•--•---•--------------------------------------------•---------------------------------------------------•-•-----••--•--. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITLL 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of h alth. Si .. ��'-"- ...... - -__-_-- Date APPlication Approved By--...-- ` k!Y.l .......... Date Application Disapproved for the following reasons-.............................................................................................................. Date PermitNo........................................................ Issued-....................................................... Date. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF H EA TH /A dl.. ........... ........OF... .............e ..+16.........................-.................. p � ' Trr#gf Bratr of uutpligar T IS IS TO CERT dividua Sewa is— sal y e o ucted or Repaired ( ) by- ----•- .......... ------•-•- -•- - ---------•-- ........... ,� .�......_... 0011 at----- . ..... �+ ---------- has been installed in accordance with thie provisions of TIT j of The State Sanitary Code as described m the application for Disposal Works Construction Permit No---—--- dated-__.11�.'../--"_-74&- -__--__--_ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUEMAS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................................................................... `r".It.1�•l.� ��.Mtl..� - �'13L�QC�OM y>;� r - L1C� C-�AC:.'b'AG-t✓ CAR(I.tO�. � � /�xP. I .tal�`( FLAW lib 3 = '3�d Ca.P•l7. P '�i� lo use- t OOC7 6b t_ , ?IPOSAt_ F'11" - IJSE IOOO GAL... a � �Mr-WALL A G_4&. = lso s P. 4 8vT-rom AOSA.= So SST=.. tt ToTAL r 41 j P .rzc.oL&TIO J to,&-rL ; �, ,w -Imi w'.otz Lr--st,. d 3 r 7 �(J9 ' " •� •� �LDI�(/�iJG /o�cl D 6 } �$; Tor T'No �vA►«r � PPS inoo luv qG,7 �� ►mot Sala 4rpp� v>sr IW. �pL. �t 133•c?� `box U 4 Sepr(C IWV. TL1►l1C I►N. 96 Q 4G'L LrzAcN _ ',e r PIT P�JIL 6A L) W r rl J e � f •i W.AS�•IE1'9 • 1�^' CGCZTCF I l~t3 P l.bT' �'t_ �i,tJ• 4 MI>�• Pn.©�t�.� LbCATIOt-4 dST Zi/tt.. torn E=- O o WATSIL i��o�o5 at� t cMILTIP,� T'�IAT TNT hw�c.c.l�JG. 5410 u PLbt..l TZ� Q�t.lcE t_IC-,�tsr�►� fC.Wti Pt_I,-(s w►-rl-� TI-t�: S4m� �I LoT- 4�- A W 17 '��.'t'1,�,h�k �.'f*Q t�t�',E��1-.1Z"+� 4�' T'►-I fT • REGIS'C'C--��D 1.AF•-tom �UZ�J�.Ync�S l LJOT t?:Cia7C-_L? U+-b ��J G�TEiLut1 1 t ca /4Ce3.S`i� 11ppt_l (- ..',t`- 11 .t.�'� i C� t��:1(�t'.'.h�S i W L �C�Y" 1_1 IJ�.` � �rt� If4/���t �• �O No. ...................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH . ................................................ I...................OF.....lt� t ......�14 Appliration for Bh4posal Works Tonstrurtion rrrmit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: `4 6 ------------- ................................................... --------------------- ................................................................... T.ca' �e,- ................... .............a.. .................................................................................................. A.7 .. ........................................................................... f k ................................................... ✓ Installer ► Address 6ce Type of Building SizeLot ..................Sq. feet U Dwelling—No. of Bedrooms.......:2..................................Expansion Attic Garbage Grinder ( ) Other—Type of Building ............................ No. of persons............................ Showers Cafeteria ( ) 04 Other fixtures ----- ......................................................................................................................... Design Flow-, ...............................gallons per person per day. Total daily ow................2...Z'......0..................gallons. 04 Septic Tank—Liquid capacity OA&lons Length................ Width.... ...... Diameter..._._........_. Depth..............._ 'Disposal Trench—No...................... Width---.---- .......�-Tbtal Length...................4,Tota 1-65ching area--------------------sq. f t. epage Pit No.....".%' 'w*"o inlet-' 0 S� n4-------- D - ----------- e�<Depf ftneo ...... otairf'eaching area..................sq. ft. Z Other Distribution box Dosin ta -7 Percolation Test Results Performed by... 24 .......14�, ....... Date...9— ------------------*-------- Test Pit No. 1­�-;.....minutes per inch Depth of Test Pit.................... Depth to ground water...._.___.__..__....___. fZ Test Pit No. 2................minutes per_,'inch Depth of Test Pit.................... Depth to ground water.._...:._...........____ 04 ... ........ ram................ ------------------------ 0 Description of Soil----q-.............................y------------- . ..........................yr 14. .......................................................................... U .......................................................................................m.............................................................................................................. .............................................................. .......................................................................................-------------------------------- -------------- U Nature of Repairs or Alterations—Answer when appjicAble.---­­--.":--------­-----------------­--------------------------------------I............... ......................................I................................................................................................................................................................ Agreement: The undersigned agrees to install the aforedescribed'.Individual-Sewage Disposal System in accordance with the provisions of T I T 1Z 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. .............................................. ­". .. . .......... .......#�; .......> S* Date Application Approved By........ -0e ... .. ......... ................. -----c / 7 04 ....................... Date Application Disapproved for the following reasons:........................................................................................................."------ ....................................................................................................................................................------............................................. Date PermitNo..........................Z......... ­------------------ Issued_.-----...------------.......... ...................... Date 011 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALT .... .......... ... .......................OF...... ............................................................................. THI k i ted 10 S'42� TO CERTIF xidual Sewa s osal or Repaired e 0 by..... ............:.te ------------------------------------------ ---10----- ..................4.:............#n—e-_2................................. V �Y ..........................o ........ ...............................................................................................................;Zr-------------------------t. -has been installed in accordance with the provisions of TIT 5 of The State Sanitary Code as described in the applica'ti6h for Disposal Works Construction Permit No.."... Zf.................. dated- ­/-7.7-trr.......... ....... THE ISSUANCE,-OF-,THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL.,�F.UNCT16K SATISFACTORY. DATE.... ..................... ................................. ............. Inspector................................................. ----------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD,QF H EAIIP;H ........ ....................OF....... .................... ............................................... No......................... FEE._..................... Disposal Works To ryi Permission is heregy granted.... ------�. . ............. ........... ....................... ... ............... A- to Constm pt' or Repair Individual S ­1D V J01— ewage '�ispds'al SysternT ..............at ....... ...... ..................I—-- ..................................... ................................. ........................................ Street as shown on the application for Disposal4orks Construction Der)nit -------Dated. 1:0, ................ ,DATE... ..................................................................... Board of Health FORM 1255 HOBBS & WARREN. INC., PUBLISHERS