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HomeMy WebLinkAbout0084 KING ARTHUR DRIVE - Health 84 King Arthur Drive Osterville _ A= 145 —042 y 'TOWN OF BARNSTABLE LOCATION SEWAGE�r2 SEWAGE # /70 VILLAGE d ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. Szeg�X o SEPTIC TANK CAPACITY e rc,.Sz!2a (0-00 LEACHING FACILITYAtype) PQ����� Pam (size) li NO. OF BEDROOMS PRIVATE WELL O BLIC�R A� BUILDER OR OWNER ��"'u5 DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No \oaU tv r Lo Svc, 'V Commonwealth of Massachusetts Title 5 Official Inspection Foam Subsurface Sewage Disposal'System Form-Not for Voluntary Assessments 84 King Arthur Dr Property Address Melanson Owner's Name Osterville MA 02655 1/23/09 CityfTown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. A. General Information 1. Inspector: Frank Nunes III Name of Inspector saa Company Name 25 Deer Ridge Rd Company Address Mashpee MA 02649 City/Town State Zip Code 508.272.6433 Telephone Number B. Certification 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 the inspection. Tfi-e inspection was performed based on my training and experience in the proper function and maintenance of on�6site sewage disposal systems. I am a DEP approved system inspector.pursuant to Section 'f ;340 bf Title 5(310 CMR 15.000).The system: ru ® Passes ❑ Conditionally Passes El Fail CO v1 . ❑ Needs Further Evaluation by the Local Approving Authority ,o r 1/23/09 Inspect es Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 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 DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. r , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 84 King Arthur Dr Property Address Melanson Owner's Name Osterville MA 02655 1/23/09 Cityfrown State Zip Code Date of Inspection B. Certification (cunt.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Pumping suggested every 3 yrs to prolong the life of the system 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. Answer yes, no or not determined (Y, N, ND) in the ❑for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is'structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backupor break out or high static water level in the distribution box 9 due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 84 King Arthur Dr Property Address Melanson Owner's Name Osterville MA 02655 1/23/09 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: *'This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No Ej ® Backup of sewage into facility or system component due to 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 El ® 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 %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 SAS, cesspool or privy is below high ground water elevation. El ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 84 King Arthur Dr - Property Address Melanson Owner's Name Osterville MA 02655 1/23/09 City/Town State Zip Code Date of Inspection , B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a'Zone 1 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. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 1.0,000 gpd,to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in.addition to the questions in Section D.- Yes No ❑ ❑ Ahe 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 E]. f ❑ Area-IWPA) or a mapped Zone [[ of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments. 84 King Arthur Dr Property Address Melanson Owner's Name Osterville MA 02655 1/23/09 Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? ' The size and location of the Soil Absorption System(SAS)on the site has been determined based on:.. ® ❑ Existing information. For example, a plan at the Board of Health. ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 84 King Arthur Dr Property Address Melanson Owner's Name Osterville MA 02655 1/23/09 Citylrown 7 State Zip Code Date of Inspection ' D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): unk DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):. 330 Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? El Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: occupied Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.):. Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 84 King Arthur Dr Property Address Melanson Owners Name Osterville MA 02655 1/23/09 CitylTown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: owner/no pumping history Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® 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) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all'components, date installed (if known)and source of information: Tank and Leach Pit'B"as depicted 1979 per age of home. Leach Pit"C" 1992 per BOH record. No D-Box Were sewage odors detected when arriving at the site? ❑ Yes ® No Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 84 King Arthur Dr Property Address Melanson Owner's Name Osterville MA 02655 1/23/09 CitylTown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer locate on site plan): Depth below grade: 2'6"feet Material of construction: ❑ cast iron. ®40 PVC ❑ other(explain): >10' Distance from private water supply well or suction line: feet Comments(on condition of joints,venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 2 feet Material of construction: ® concrete ❑ metal El fiberglass ❑ polyethylene ❑other(explain) Riser to outlet end If tank is metal, list age: yearn Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No --------------------------------------------------------------------------------------------- ----------------------------- Dimensions: 1000g Sludge depth: 61� Distance from top of sludge,to bottom of outlet tee or baffle >12' Scum thickness 1/2" 10 Distance from top of scum to top of outlet tee or baffle '2 >211 - Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? measured Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 84 King Arthur Dr Property Address Melanson Owner's Name Osterville MA 02655 1/23/09 Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑' innovative/alternative system Type/name of technology Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Pit"B" is 3'6"below grade and equipped w/a riser to 3"of grade. It is full and equipped w/a T to serve Pit"C". Pit C is 3' below grade it does not have a riser. It has 1'of liquid in it at this time f I C t, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 84 King Arthur Dr Property Address Melanson Owner's Name Osterville MA 02655 1/23/09 City/Town State Zip Code Date of Inspection D. System Information, (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. 41 . ftc qq .r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 84 King Arthur Dr Property Address Melanson Owner's Name Osterville MA 02655 1/23/09 Cityrrown State Zip Code. Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: feet feet . Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: Cape Cod Commision web site You must describe how you established the high ground water elevation: see above 33 pa d Lr D.f ►ve 5 33 E 2d i 2 Y 42� 1 r ' . Eek 3IUOO f: °o � pt-oP.uSe� 1 . ASSESSORS MAP NO: f � "PARCEL NO: _ No....?.J:.r.170 THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABL.E Appliratiou for Uiipnsal Workii Tonstriartiou rjernfit Application is hereby made for a Permit to Construct ( ) or Repair`{-�an Individual Sewage Disposal System at: ^--�—�Loc ion- ddress or Lot No. ��•.••��� ......................... ^ ................ .....................ate....----•----..... ..... • Owner �! �/- t...................... •--•.................�...... Lc�r1nQ ��- -�:�1'c .—..... ...............PL U� .` � T.Addye;s..V Installer Address Type of Building Size Lot-------------------- -----Sq. feet Dwelling—No. of Bedrooms___...:...............................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures .._...... W Design Flow........... ' -...........:......gallons per person per day. Total daily flow...... -�zv....................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.__...(„v.._--___ Depth below inlet...V.......... Total leaching area..................sq. ft. 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........................ 4� Test Pit No. 2................minutes per inch Depth of,Test Pit.................... Depth to ground water........................ 0 9 --••---•--•---•-•---••••----•-•-•-••-•-••-•--•••-••-•--•-------•--------•---•---•••-•...........................••••---.._..---•---•---••----...---•--....... Description of Soil........................................................................................................................................................................ x U ••-•••-------•-----•-- .................................................------•--•••----.....---••----•---•-•••----•------•----•-----•-•---••...----•--------•-•••--••----•---•---•----•-•.......---••- W x ...............-...................................................................................................................... U Nature of Repairs or Alterations /—Answer when applicable.__-_ ie---- ---------6.-��...�- ?-Ge---------V.4'..._.. Ems/ �S �� v� C Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee Kissed�,bthelth. S 9ed--.--_A. . .. ..... ---.------- .......�'C�C �- Daw Application Approved BY "- . ... e..Dale Application Disapproved for the fod owing reasons- -- ----------------------------------------------------------I........--............................................................. Dace Permit No. .......... a` _7.e7 ........................ Issued Dace No...? a7o FEs.y ... . THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE ApplirFa#'tun for Disposal Works Tonstrnrfiun Prrmit Application is hereby made for a Permit to Construct ( ) or Repair `(- an Individual Sewage Disposal System at; Loca ion t - ddress or Lot No. - v- - ... ......................... ..._..-•----------...... V -......... -- ----..._...--•--...-------........--••-..-•--- Owner Add s Installer V � Address UType of Building Size Lot____________________ _____Sq. feet Dwelling—No. of Bedrooms-----3 3................................. Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria`( ) Other fixtures ------------------------------------------- -------------- w Design Flow.......... _'?�-..................gallons per person per day. Total daily flow...__. C?___....__._.__......gallons. WSeptic Tank—Liquid*capacity............gallons Length................ Width................ Diameter...__._......._. Depth................ x Disposal Trench—No. .................... Width.................... Total Length----------.......... Total leaching area....................sq. ft. 3 Seepage Pit No........I........... Diameter__....j;U....... Depth below inlet....1 D9.......... 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........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 0 a .--••----_------•---•--••-------•••-••-•-----•-•-••-------•-••--•--••-•-----••.............................................................................. Description of Soil...............................................................................--------------------------------------------------------------------------•_-_--....._.. x U .....•-••--•---•----••---_---••--•--•--_-_-•-••-••-•--------•------------------•---•------•---__••-------...----•---------------•----•-•------•-----•----•-•--•-..........__-_--_•-•--_-•---••-___---_••- w U Nature of Repairs or Alterations—Answer when applicable.__�'.t/�-��� 1�_.._...C_a��._.C_��' G�._.�___�...__. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been iss ed by the bo d of health- . _ S'gne � ... _ ' :"� ._y. ............. _ Dare Application Approved By ------ -------i �... / -.mac Application Disapproved for the following reasons- ---------- ------------------- ------------------------ ------------------------------------............. ----........ ------ -------------------- -----------------------------------................................... ---- ----------------- ----------------------- -- ------- ...................-------- ............................ ------ Dare Permit No. .......... .....J-7(........................ Issued .............. -----................. Dme THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE (IerttfiratP of C�umpliance THIS IS TO CERTIFY, That the Individual Sewa e Disposal System constructed ( ) or Repaired ( by.................... ................................. l( 4=... -...... Inscalle at ? ...... AL ------------------- S.t................---------------......................-------- has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ...� .-.--1.-7?....�...-- dated ......................................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY: A DATE-........ ------------ ............ Inspector ` - ( a '► (1 ;// THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH !� 7a. TOWN OF BARNSTABLE FEE.. ...� � Disposal Works Tonstrudion ramit Permission is hereby granted........./-A... .......................................... to Construct ( ) or Repair ( an-Individual Sewage Disposal System at No..---•---••------••---�f--(...-•. 6- �----.��=f�'!c �•Jvct _, ��5?cr Street as shown on the application for Disposal Works Construction Permit Na2s�:176_ Dated.......................................... ................••--•---•_.. . ................. ey ?� Board of Health DATE.................. �.� .=.1-� ' - FORM 36508 HOBBS&WARREN,INC.,PUBLISHERS ' AsBuilt Page of 2 TOWN OF BARNSTABLE LOCATION �i `{ �� �+ � ALIT SEWAGE # - 170 VILLAGE O ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO._ y&e—�_04 q 5:r0-%Z SEPTIC TANK CAPACITY [p LEACHING FACILITY:(type). (NZ-e--GWC ptZ" (sie) (pr6-g 0tSXc`(l NO. OF BEDROOMS PRIVATE WELL O BLIC�R•t/ BUILDER OR OWNER O� ��`°"��L DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes- No yEb-�j.i 1�►c� �c-mSr p tz ' N �:CT1���7yr GLJ`ar sZ o http://issgl2/intranet/propdata/prebuilt.aspx?mapp,-r=145042&seq=1 2/21/2017: No.- • ........_.... --- Fps..... ........... . THE COMMONWEALTH Off' MASSACHUSETTS BOAR® OF HEALTH y(- ................OF. rt.....--y •---•-- .................................. ApplirFatinn for Di-opuiiaal Works Tonstrnrtiun Vernfit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at_ e .�it'LAoLcati Addr s / Lot N .......••• ......•^».... `... = .... Erf >f�: �° . .. .f�lanC .. ner Insta .� Address � Type of Building Size Lot._t_X,.uje�®--....Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder p,, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other xtu ! w Design Flow...........................................gallons per person per day. Total daily flow.......3.3.4.......................gallons. WSeptic Tank—Liquid capacityl-VI"..gallons Length....... Width...e........ Diameter................ Depth................ x Disposal Trench—No..................... Width_ ....... Total Length._.__.P ._.... Total leaching area....................sq. ft. 3 Seepage Pit No----------�........ Diameter........ .. Depth below inlet__.. Total leaching area...7-e.1....sq. ft. Z Other Distribution box ( ) Dosing t (y ) � "6_ ►!# aPercolation Test Results )r Performed by-_�: `'� / ........ Date---1 ._'. a.- 7 Test Pit No. 1.....R;�-----minutes per inch Depth of Test Pit...... ......... Depth to ground water...IV.—4 r Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water...................... G4 Description of Soil - '.. ...-•--•------- ..... ..�1_ ----.Y.............. x w UNature of Repairs or Alterations—Answer when applicable............................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TLI=j 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. Si ed -- ..� • _� ��1. .............- .2.,F_. .. �� _- te Application Approved By..... �y} l• ........................... .--••-• - 7r� Date Application Disapproved for the following reasons:-------•-----------------------•--------------------------------••......•--------•-i............................... .........................:............................................................................................................................................................................... Date Permit No..---...-•-------•--.._..._...•. •---..... Issued--- �'2 `-------------- I d ........................ Date f No....................f FEs.... .. ,.,. THE COMMONWEALTH OF MASSACHUSETTS w BOARD OF HEALTH CI►�Q✓.. ...... ....OF... --------------------------------- Apphration for, Dispoii ai WorktiT�onstrurtiun ramit k" A lication is hereby made for a Permit to Construct" or Repair an Individual S.etg ge Disposal PP Y )" P ( ) � P System at,: ............................ ........................... ------. .--- -..... .... • Locati Add ss ......... ... .... . --• ..... , ,5 ner W �.. tw y k aw} a Insta Address . Type of Building Size Lot- 4_0?A____--Sq. feet ,., Dwelling—No. of Bedrooms. Expansion Attic _ Garbage Grinder pa, Other.—Type of Building ........•......._..•_:... No of persons oris --_•-_----. Showers ( ) — Cafeteria ( ) ; -Other s¢ot�t Design Flow............____ ..----. g P P P Y Total daily flow...._. ............................gallons, Wt __._ gallons per person er da R; Septic Tank—.Liquid capacity! :_gallons Length __,Width.. Diameter-:__-_ .. Depth................ DispgsaItTrench—,-No .:.. __. Width._ . Total L"ength. .... "°Total leaching area.....................sq. ft. Seepage Pit No s Diameter......... Dept 'below.i eta.._. '�__ Total,leaching area.- ./___-_sq. ft. Z Other DY tribution box�4. ) Dosing nk )� `� ' Percolation Test Result`s M Performed.by S minute's;per inch `Depth of Test Prt ... De. th to oilnd water..Test,Pit No. 1__:-- .._. P Test Pit No. 2................minutes per fich .Depth of� Test Pit.................... to ground Water -____................ r _ ' r 0 Y O Description of Soil _ � �___'' ..'' .. .".' "- -- ------------------------------------- •--•---------------------------------------=------------------• -----------------•-----------•------...-•------------------------------------ •---•-•-----•-- U Nature of�Repairs or,Alterations—Answer when applicable____________________ _______ _ ______ ._ ..... .:_.._........__. x _ R, •, ,� f , i Agreement: The undersigned agrees.to install'"'the aforedescrijped Individual Sewage Disposalystem in accordance with S the provisions of i� } t k '' p ,�' S o the State Sanitary Code—The undersigned further agrees not to place the system in. yCif operation until a Certificate of Copllanc ^--has bee yssued;by theboard of health ed S - d/ " f.ar Application A rove Date Application Disapproved f d the f olloung reasons:................................................. � Date C7 t Permit No .. ............ --_ Issued _..._. •--•- ....•• ....................... l - Daze ' - * - THE COMMO:NsGVEALTH OF MASSAC.HUSETTS 1 r" BOARD OF HEAL' H .... OF... :,:,..:....... ... Y Y Trrtifirtt#r of TompliFanre THIS S TO CERTIF T t,,th na.vid Sewage L?i osal fS em constructed (�17or red ( ) ;. by........ 7. .... '` - ' -------------------- Install s " ey at.._...... .... ....... , . . ---- ••--- has been installed in accord ice with e 'Visions of j of The State Sanitary Code d ribed in the y s< application for Disposal Works Construction Permit No�- - -'�-----:............... ` dated_-3_`.._ ............... THE ISSUANCE OF THIS CERTIFICATE SHLLNOT BE CONSTRUED AS A GUARANTEE THAT TH SYSTEM WILL FUNCTIONS SATISFACTORY .` z/ q DATE............. Inspector.. � rr` .. THE CRMMONWEAL"T.;H'OF MASSACHUSETTS BOARD Qfl, HEALTH (l." .. OF No.........�"�.�... FEE.,. ........... rdV � ..Per"mr. > to rm sion is granted � :::...: ._ � .' :..to' Cons t'° pair ( aid"Indivi nal Se ge Dispo Syem 1 ..................................� .... .....................at No.._ �x Street �Q ication for Disposal Works Construction Pe mit N Dated....................ti� /_.____.. a jl C- • as shown on the.,, 1 , .- PP {; ....Yll ---Board of�He / �•-"-s .................. DATE :.:.........: ...... FORM''12'SS HOBBS,& WARREN, INC.. PUBLISHERS i IjdIL.,,( FLoW = 11O 4-9 r� u sue- t o0o S 6 L. 'Gv ,� _N PIT - L-)SF Io00 Gza �ITFW�S,LL AeE.A = lSD S•F. __� ISo sF 2.s = iS 12 P}�rcc * = - �z G BVT'TQ d iK ACQ r" ri `S-. JCA✓CLLI r S - -'+ Sd C->.PD. I TOTAL 42S G.PD. ToT,6 L L\-f rw.,A-/ vL Pr-QCDL&T10Q Z&-rE �� Iki I-AAI I.1 orz LESS. 1 Per T0? FNo =ioo.o Low � l000 IM/. •:� `1(,.41 'SeprIC IwV. Tiat!le. 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