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HomeMy WebLinkAbout0121 OLDHAM ROAD - Health 121 OLDHAM ROAD, OSTERVILLE A = 120 120 I o r I o i NO. I `F' Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ftpYitation for Disposal 6pstem Construction Permit - Application for a Permit to Construct( ) Repair V) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. /2,o /10 11 Owner's Name,Address,and Tel.No. Assessor's Map/Parcel 121 'Q 1-66 0( /ZIP. C)61""evtlle -PP qR 1 C K R . Sy Lv ESTeR Installer's Name,Address,and Tel.No..5C>Q'- -y 1- -t618 I I Designer's Name,Address,and Tel.No. T�pe of Building: Dwelling No.of Bedrooms / Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided VIA= gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 11Y G�k np_w beg 4420 -oX to. / rmcr A+4t) Coub-n- ` „ /3CLOW 62+-bDE Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environme ode and not to lace the system in operation until a Certificate of P P Y P Compliance has been issued by this Board alth. Q Signed .� Z� Date U� z Application Approved by M Date /�O Application Disapproved by Date for the following reasons Permit No. Date Issued Ulu *- -------------------------------- ------- -_-__=_=___--=_=_____� - - - ----- t rn h + No. Z" ` e Fee ✓,. THE COMMONWEALTH OF MASSACHUSETTS i Entered in computer. PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 21pphcation for Misposal 6pstem Construction permit n.� Application for a Permit to Construct( ) Repair(x) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components. Location Address or Lot No. 12-01/a Q Owner's Name,Address,and Tel.No. Assessor's Map/Parcel 1 Z 1 Q L>7A+q 2s>. cg4,I/le _R,1 R 1 GK R . S y LV ESTIE R LTI Installer's Name,Address,and Tel.No. SC 9-, -y `I Designer's Name,Address,and Tel.No. Type of Building: !i P2e'1 G�✓ Dwelling No.of Bedrooms N •Lot Size sq.ft. Garbage Grinder( ) Other Type ofBuilding No.of Persons Showers( ) Cafeteria( ) Other Fixtures , /. Design Flow(min.required) N A gpd Design flow provided_f - gpd Plan Date Number of sheets Revision Date Title ' �.� Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) T,,N i.% Zo 'x Lv CGy 614.,oE . Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a.Certificate of Compliance has been issued by this Board 9VHealth. _ v _ q .t `SI ed-- -- , --. _. _ _ , " -•, l' -:.:.C.j+.-^' 'Date-�-=-� -,- ._ .�--°�-- Application Approved by / --r~- Date V:> Application Disapproved by Date for the following reasons Permit No. ? r 1 D ( Date Issued -.----ter,:-- w a.._- r v - ------------ THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance r THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(i.,.)-''� Upgraded( ) Abandoned( )by � - at (7 cA has been constructed in accordance I with the provisions of Title 5 and the for Disposal System Construction Permit No. 4- L 9J 30kdated /(p f I J i Installer I Designer #bedrooms M l_ Approved design flow A. gpd The issuance of tl�s' permit shall not be construed as a guarantee that the system will fi>�Ictie as 'esign d. Date Inspector .� _. o ,30� Fee / .r--'------- _ . N THE COMMONWEALTH OF MASSACHUSETTS ,Q PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Bisposal .pstem Construction permit Permission is hereby granted to Construct( ) Repair(�,.)� Upgrade( ) Abandon( ) System located at '7 i `. G _ ��... and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. 1 . Provided:Constra�o must be completed within three years of the date of this permit. Date �;�• Approved by i /� va <,q COMMONWEALTH OF MA,SSACHUSETTS OCR ► , EXECUTIVE OFFICE OF ENVIRONMENTAL AF DEPARTMENT OF ENVIRONMENTAL PROTEC t om ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 r`99 & �,1 WILLIAM F. WELD OXE Governor '� ecretary ARGEO PAUL CELLUCCI DAVID B. STRUHS Lt. Governor Commissioner ,2U SUBSURFACE SEWAGE DISPOSSALSYS"I'EM INSPECTION FORM T p �,o-` 110 0 CERTIFICATION Property Address: ,2\ CK�-V\IclVv�l ( t Q�����1`LA__, ' Address of Owner: Date of Inspection: I O' 5 `ee (If different) �'qU Name of Inspector: tA tLxn.r�L`J I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: .� Mailing Address: �•C'i .. r, Telephone Number: n ;��-11 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: Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fai l Inspector's Signature Date: `6 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 b low. COMMENTS: Tt b1A q . Su c, , 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. 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, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exftitration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04/ZS/97) Page 1 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: a B) 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 inspection if(with approval of the Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced _ The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed s. - C) 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 failing to protect the public health. safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERIMIN"ES THAT THE SYSTEM IS NOT FLTCTIOND;G IN A MA.NrN'ER WI-DCH WILL PROTECT THE PUBLIC HEALTH AND SAFETY A:YD THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERNUNES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRON,I•IENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. _ The system has a septic tank and soil absorption system and'the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER 1 , (revised 04/25/97) Page 2 of 10 y^ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: - DI SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessity to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. rface of the ground or surface,waters due to an overloaded,or clogged SAS or Discharge or ponding of effluent to the su cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool, Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the.last year NOT due to clogged or obstructed pipe(s). Number of times pumped _. Any portion of the Soil Absorption System. cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds. ammonia nitrogen and nitrate nitrogen. T E] LARGE SYSTEM FAILS: V You must indicate either "Yes" or 'No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: 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: Yes No ,. 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 U 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 further information. l Page 3 of 10 (revised OSR5/9'n � 1 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 2-1 C) (� 11CjIN\ Owner: e �� Date of Inspection: Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: —P. No Pumping , information was provided by the owner, occupant, or Board of Health. _ None of the system components have been pumped for at least two weeks and the system has been receivine normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. All system components. excluding the Soil Absorption^System. have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, naterial 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: The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub Surface Disposal System. Existing information. Ex. Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)j µ (revised 04/25/97) Page 4 of 10 1 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORIM PART C SYSTEM INFORMATION Property Address: 1 Owner:.(d60 N Ck fJ Date of Inspection: 16 ��(_, TJ FLOW CONDITIONS. RESIDENTIAL: Design flow:_a,'jgL_g.p.d./bedroom for S.A.S. Number of bedrooms:LD— Number of current residents: Garbage grinder (yes or no):_tt—% Laundry connected to system (yes or no):� Seasonal use (yes or Water meter readings, if available (last two (2) year usage (gpd): Sump Pump (yes or no): Vj Last date of occupancy: l COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow:_ allons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present. (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GE`'ERAL iNTORMATION PUAIPM RECORDS and sourc of informs•on: System pumped as part of inspection: (yes or no) If yes, volume pumped: gallons Reason for pumping: 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) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: C C Sewage odors detected when arriving at the site: (yes or no)�b (revised 04/25197) Page 5 of 10 I� 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: NOC`j(JG r. Date of Inspection: L BUILDING SEWER: \ (, (Locate on site plan) Depth below grade: Material of construction: _cast iron 40 PVC _other (explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK:-,j (locate on site plan) Depth below grade: �T l L Material of construction: Lconcrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list ace _ Is age confirmed by Certificate of Compliance _(Yes/No) Dimensions: �UCX') a1 Sludge depth: Coy tt Distanct 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: I ZL ( Distance from bottom of scum to bottom/ of outlet tee or baffle: n How dimensions were determined: 1 ia:t R kh A Comments: (recommendation for pumping, con ition of inlet and outlet tees or baffles, depth of li uid level in relation o ou et invert ttuctural integ evide ce of leakage. etc.) o GREASE TRAP: (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain) Dimensions: 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 baffle: Date of last pumping: 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.) (revised 04/2997) P2ge 6 of to { t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: (a I , TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection) (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Alarm in workinc order _ Yes: _ No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches. etc.) tISTRIBUTION BOX: S (locate on site plan) Depth of liquid level above outlet invert: `'j( Comments: (note if level and distribution is equ I, idence of solids carryover, evidence of I ge into or out of box, etc.)- PUMP CHAMBERP�:hD (locate on site plan) Pumps in working order: (Yes or No) Alarms in working order (Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) l t (raised 04/25/97)1 Page 7 of 10 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C 1 SYSTEM INFORMATION (continued) Propert��A(�dd60ress: 1Ik �����"� , Owner:4 U4V Date of Inspection: 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: U leaching pits, number: (,IL \ leaching chambers, numb leaching galleries, number: leaching trenches. number.length: leaching fields. number, dimensions: overflow cesspool. number: Altemative system: Name of Technology: Comments: (not con ition of soil. signs of hydraul' failure, level of ponding, ondition vagetatio tc.) h C� tt t t� L! CESSPOOLS: (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: r ,� Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY:_ (locate on site plan) Materials of construction: Dimensions.,, Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (raised 04125/9T) Page I of 10 t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Z ( 0ka vCxW\— Owner: Date of Inspection: O SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) \ZA 2 0 (revised 04/25/97) P2ge 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR NI PART C SYSTEM INFORMATION (continued) Property Address: kar� -,, Owner: �-w#.V� . Date of Inspection: 5 Depth to Groundwater J:2�OFeet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators. installers 1-1 Use USGS Data Describe in your own words how you established the High Groundwater Elevation. 11ust be completed) i i (revised 04/25/97) Page 10 of 10 TOWN OF BARNSTABLE 11-�XATION SEWAGE # ) LAGE ' O9—C-"`AU ASSESSOR'S MAP &LOT I to, INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY ;—O—c-Av,*- LEACHING FACILITY: (type) (size) NO.OF BEDROOMS o� _ BUILDER OR OWNER 1J0n tUjo 1- ] PEMITUATE: ( O� ��1 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to th ' ' y Feet Private Water Supply Welland Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) �` Feet Furnished by __.� -��---�-- _ 1-- --.__.___.._.._�.___--.-.._. � �21 � Q�6� � 2 3 � � 6 � � 3� � 6 `� TOWN OF BARNSTABLE SEWAGE # if X—LAGE. ' ASSESSOR'S MAP & LOT 1 Z=0 t INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACPTY �C70;©—c4�- LEACHING FACILITY: (type) �� (size) (00C)Cl V1- NO.OF BEDROOMS BUILDER OR OWNER PTI'bATE: I O, `� COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to th y 2-0 Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) N Feet Furnished by J � l21 2 e No........ .�J...r!.rrt: F:m$ 3r............... THE COMMONWEALTH OF' MASSACHUSETTS BOARD OF HJEALTH .o....N..........OF.....l�c�.h t,a..s.. ..C�...R.. ..' .._............................... Appliration for Disposal Works Toustrnrtiun thrmit Application is herebymade for a Permit to Construct K�or Repair an Individual Se�`" ) p ( ) Sewage Disposal System : J r v -® ...... - .... �� - Location dress r Lot N j -- ................... r Add s ..................................... .............1� ,� `o .---.......41-_l s Installer Address UType of Building Size Lot... -----Sq.�f� �-, Dwelling—No. of Bedrooms.....3................................Expansion Attic ( ) Garbage Grinder V 4— aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) 04 Other fixtures .• ----- Design Flow_.:...__y�, .`=_:._..'.....�-.�.••.g�allons per person per day. Total daily flow......... .1�0.. ....--....._gallons. W Septic Tank i Liquid capacity/.���llons Length................ Width................ Diameter................ Depth.. ........ x Disposal Trench—No..................... Width.................... Total Length.............. Total leaching area... a._K...sq. ft. Seepage Pit No.........I......... Diameter......�........ Depth below inlet--- ------ ------ ,otal leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ) C I D — a Percolation Test Results Performed by._. , + ' 1I.?z_ ' �_. Date_:: ------------------- Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water......................... fZq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 ........l ------ ......... Description of Soil......__. _ � a 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. Siwed-----.... ................................................................. • Date Application Approved BY------- r- L - ....................... Date Application Disapproved for the following reasons----------------------•---------•-------------------..................-=----------............................. -•--------- ------------------•----•------------------------------------------------•--- Date PermitNo......................................................... Issued........................................................ Date THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINAL (S) I M A�C&, 7L DATA _V� NFEB...."`—................ THE COMMONWEALTH OF MASSACHUSETTS BOARD_ OF HEALTH u w N �'7, r ' ........ ................................OF........ .1 .. !. ..�..`.'..�-------�'---------........................ Appliration for Dispnnaal Works Tonstrnrtion frrutit Application is hereby made for a Permit to Construct '() or Repair ( ) an Individual Sewage Disposal System at: Ll _� Locations{---Address R[ or Lot/No. .. ! r• 1 h E t.............................................. .V 5 t S f L_............................................ / . �. J Owner. A��ss " Installer Address Type of Building Size Lot-_f-----—----_`-------Sq. fept Dwelling—No. of Bedrooms___...................... .Expansion Attic ( ) Garbage Grinder }. --------------- pa,I Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) P4Othe fixtures --------------------------•--••--•-•----••--••--•••-••--------•---•----••......•. W Design Flow .... ,� "_ _____ ________ _gallons per person per day. Total daily flow......... .. ��..._.._� � ___Septic Tank Liquid capaciti/---------gallons Length................ Width .......... Diameter--.---_.-___--_. Depth............... Disposal Trench—N ._._.._-.--••-----•-. Width�.................... Total Length-----�,� ........ Total leaching area. 47-1....sq. ft. Seepage Pit No........ .... .... Diameter.....e..._..... Depth below inle© R_�_ Total leaching area____.-......-:....sq. ft. Z Other Distribution box. ( . ) Dosing ta,4< i ) Percolation Test Results Performed by... ./1.:.�?.�!..�......__._f .Vo..�`9!t-_- Date'.-/---a� 7� a , 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 1 =- O d 2t P = Description of Soil 6t dl` .... ". _..:.__ ................... .. . -►�---- d - x U - --------------------------------------------------------------------------------------------------••---•-----••• W ---••-••••-•----------------•---------------------------------------------------------•-------------------------=-----------------------------------`---- - -- VNature 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 iITTIE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of tSompliance has been issued by the board of health. Signed... - ------------------- ------------------ -•--•----- Date Application Approved By.......r� ..... --------------- Date Application Disapproved for the following reasons:................................................................................................................. _ ----------------- .............................................................. --•---------•....--'••-•--•-•---••---••-----•-•--------•-•-•-•------------••--•-•••............----- Date Permit No------------= Issued...-----••---••............---- ..... ............ -•--------- --•--•--------•-- ---•--..... � Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH. / IU u.J tJ . ..r✓....: `..... .....!......................................................... .... (In ifirate of Toutphatta THIS.IS TO CERTIFY, d( . ) or That the Individual Sewage Disposal System constructe Repaired ( ) 0 61�✓ f .. 'X..by ---••---•--------------------------------------------------•. ---------------------........--------•-•-----.....--- ' /' InstalleJ;�r at has been installed in accordance with the provisions of of The State Sanitary Code as described in the application for Disposal Works Construction Permit No ............................. dated-----P!!�j.....;?:_g.................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSJA11UED AS A GUARANTEE THAT THE SYSTEM W L FUNCTION SATISFACTORY. DATE.......... ....................................... Inspector .........-••-------•.•-- ••. ----------------- THE COMMONWEALTH OF MASSACHUSETTS 7- BOARD OF HEALTH/ ,S-j ....... .............................•••--••......••. �� No......................... FEE........................ �in�o�aa1- �rk� �onn�rion eruti� Permissionis hereby granted..............................................---------------------------•--------------------------.._....... ........---...--- to ConstructG(!) or Repair ( ) an Individual Sewage Disposal System at ........... ' � 1//,'7f./ �,..... " ------------- / f ! f Street -••.....................•-••................ as shown on the application for Disposal Works Construction P4ertpit N ____________ _ __ Dated....l_.......A`71--�............ ...4 -0.1 u''' -,:-- •-„-.-_---_------•----•-•- Board of Health' DATE........................... ...................----------•---•---._..--•- , , FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS h. S1 LE � h►`�_! - S I3t�DtzoanA T l Lam! ;:l..CKAY = 110 ". -S = 330 t� 41 -SE�-Ie -rA4-IV = '41 . _ _t>i5Po5A. _._ppT - usE loo6 GAL . 15MGWA, I Ae = tso tC,o SF .c 2.S = IS G.RL7. iG _ Dwbi.4.t+JL �L BorrroxA CA yam. A ► .o SO .P D. TOTAL 4ss G.P.D. f ToTQ L tat t L�f FLDW = 33p 6.PD. t3 I _ TAWL tt}ZGDL&TIOLJ CZATE ["to 2M11u Otz Lass. �-- PIT r s Itz ► MUHARD A' n. 00 44 S v ire.. t 'TAT ,. ' �"•('„=� � •,;�, ToT �N{y +��oc�.o �126�"I �iiinZ` .'r Itirl�'�r C LoAw � � PPe loan IIN. '" Srnscltw. 4'PP,& visr Iw. �Q�. 9L8 2'1z INV. '8oK K 10 1 DoO U.0 LSA I4 PIT e' CJ�� WASN�D STONE ,p CE[ZT1i�D pL-O Ci'Ssy 12 �..!o ��' c ts,ti..+�- �.�A.,�. _l l�� �A."'i'>✓ g ( -7 9 GGtzTt4=�( 744AT Tt-iF-�- t Iurtu.+I.1r, 5tiarvu - Wt.,?t=nI,l f(:WkPLq'G W►TI-i Tt-1�: SIDE`.t_t►-lE= LOT- 4 Aua �:ETt�ncl: �'C-�Ut�EN1c1--lT�� or- -c'►-tom: -TO w L-: Or STVV I L La U.,)OOOS' l7A't'C t3lS.�CTC- c`. wll�,I✓ If--1c- t2cGt5,razz GD i�btG SU2Vrr`(UtZ� T t-1 l 5 C7 C_A ti,-1 t�� LJ OT �A.ss ev v 1-4 4 W Os-rEr-V11.LC-Lc o 11.R�r('Ct1A✓l C.l•1-i rjt)� �/L=`t' ; "C1at� 0 j���i 614OWLn APPL.t CA I- l-7 _ I,k-"t' C[_ Ur-,GD j�, L0CATIO SEWAGE _T NO• VILLAGE i I N S T A LLER'S NAME i ADDRESS P z. 0 U I L D E R OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED t :I LO CAT 10 SEWAG �t � T NO. VILLAGE I N S T A LLER'S NAME & ADDRESS GUILDER OR OWNER D A T E PERMIT ISSUED Lp DATE COMPLIANCE ISSUED P} i i4l I I P