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Home My WebLink About0079 STONE HORSE ROAD - Health 79 STONEHORSE Ro[;QOSTERVILLE d A = u , 1 flo 0 p o o � O 0 a U O I 9 TOWN OF BARNSTABLE LOCATION 7: nJ v J SEWAGE # VILLAGE`' 1 . % ASSESSOR'S MAP-& LOT INSTALLER'S NAME&Pir6Ni NO. Fo 6 ��'- d.r�& A! 7 s7 5"�: T-7 " SEPTIC TANK CAPACITY ' LEACHING FACILITY: (type (size) NO.OF BEDROOMS BUILDER OR OWNER"~:'W1 �, ' PERMTTDATE: COMPLIANCE'DATE/�._ Separation Distance Between the: 01 ..E Maximum Adjusted Groundwater Table to the Bottom of: ea c ng Facility Feet .-. Y Private Water Supply Well and Leaching Facility (If any ells exist,: ! on site or within-,.'*feet of leaching facility) Feet Edge of Wetland and l eaching Facility(If any weak ds ezist within 300 feet'of leaching facility) y`. Feet Furnished by � .`tea S.d� • .F� ,`.�_% '4 .•4 *�.�� ., '� .( W 1 K3: ',,mac`:. ... ,� °�. - zo7 No. Fee $5 0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Izz Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS ZIPPrication for Mtgpogaf *pgtem Congtructton Vertuit Application for a Permit to Construct( )Repair( X)Upgrade( )Abandon( ) El Complete System O Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. 79 Stonehorse Rd.. , Osterville , MA Edward Mileff Assessor's Map/Parcel In t er's e,Add s�,and Tel.No. Designer's Name,Address and Tel.No. m. . Robinson Septic Service PO Box 1089, Centerville Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Sand. Nature of Repairs or Alterations(Answer when applicable) new Title-5 leach system D-box, gas baffle , and. 2 leach chambers 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 Certifi- cate of Compliance has been issued by this B d tealth. Signed ��L,�b �� Date Application Approved by 14 44 Date Application Disapproved for a fol owing reasons Permit No. ��— Date Issued l�• fr f'No. � Fee $50 r ti' THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes � iPUBLEIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS hpplication for 30t5pooar *pgtem Congtructton Perm-it Application for a Permit to Construct( )Repair(X)Upgrade( )Abandn( ) ❑Complete System ❑Individual Components vLocation Address or Lot No. Owner's Name,Address and Tel.No. 79 Stonehorse Rd. , Osterville, MA Edward Mileff Assessor's Map/Parcel I r's e, dd sS,and Tel.No Designer's Name,Address and Tel.No. _ L me. r: oinson Septic Service r r PO Box 1089, Centerville Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date i Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Sand. ! Nature of Repairs or Alterations(Answer when applicable)) new Title-5 leach: system D-box, gas baff e, and 2 leach chambers Nk Date last inspected: I Agreement: - ' The`undersigned agreesato 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 Certifi- cate of Compliance has beeli issued by this B d ,ealth. Signed/�� _ Date - Application Approved by Date Application Disapprove 4 for e Awing reasons a Permit No. A 9'- h a Date Issued THE COMMONWEALTH OF MASSACHUSETTS Mileff BARNSTABLE, MASSACHUSETTS < Iterttftcate of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired )Upgraded( ) --Abandon Wm• H. Robinson Septic Service at �4 S�bone orse K .. , S ervi e, has been cons cted in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated .h 0 Installer Wm. E. Robinson S r. Designer The issuance of this ernpt al of be construed as a guarantee that the s will functio' des' Date Inspector - -------------jam` Li 1` ----`'-�1 ---------------- No. , Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Mileff ltgpooal 6pgtem Congtructton Permit Permission is hereby granted to Construct( )Repair( X)Upgrade( )Abandon( ) System located at 79 Stonehorse Rd.. . Osterville , MA A. and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date: - - Approved by r� , T 1/6/99 NOTICE: This F4rm`Is To,Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) I William E . R o bins on,..S,'hereby certify that the application for disposal works construction permit signed by me dated 7 , concerning the property located at 79 Stonehorse Rd. ,Osterville , MA meets all of the following criteria: • The failed stem is connected to a residential dwelling only. There are no commercial or business YThere �ed with the dwelling. • classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. • o wetlands within 100 feet of the proposed septic system • o private wells within 150 feet of the proposed septic system • increase in flow and/or change in use proposed • no variances requested or needed. • The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] • If the S.A.S.will be located with 250 feet of any vegetated wetlands,the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) B) G.W.Elevation +the MAX.High G.W. Adjustment. _ DIFFERENCE BETWEEN A and B SIGNED : iv 1/ DATE: [Sketch proposed plan of system on back]. q:health folder:cert �� 4 �3��, 1C r � �� TOWN/ OF BARNSTABLE LOCATION Q 9 L57l a �: 1�1�z,j:= SEWAGE'# VILLAGE_ . ASSESSOR'S MAP.& LOT INSTALLER'S NAME&PHONE NO. li o : �- 7 7 `fir Z SEPTIC TANK CAPACITY -/6 6 0 LEACHING FACILITY: (type)02— S' 9 L (size) NO.OF BEDROOMS i BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE�� Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any,wells exist on site or within -.... flan 2 00 feet of le aching facility) �;� Feet Edge of Wetland and Leaching Facility(If any wealands exist within 300 feet of leaching facility) Feet Furnished by 4. 7 .. �., I � 1 I ; YE y� oYs=1,r C0MMO.1\3 7EALTH OF MASSACHUSETTS — ! ExECUTIVE OFFICE OF E,\VIRONMENTAL AFFAIRS A DEPARTMENT OF ENviRONMENTAL PROTECTION Ip o� ONE WINTER STREET, BOSTOr rL9 0210r t61;) 292-550ii TRUDY CORE Secretary ARGEO PAUL CELLUCCI DAVID B. STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Adores.,: 79 S t o ne h o r s e Rd... ,NameofOwner Edward. Mileff 0 s t e rev]i l le , MA address of owner:_same Date of Inspection: /6—`,S- Name of Inspector:(Please Print) ��lil• E • Robinson Sr . 1 am a DEP approved systerriinspectOr pursuant to Section:15.340 of Title 51310 CMR 15.000) company Name: Wm. E. Robinson Septic Service MaiTingAdd►ess: P 0 Box 1089, Centerville, MA Telephone Number: CERTIFICATION STATEMENT 1 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 sea'sge disposal systems. The system: P/ses Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails Inspectoi s Signature: .,,..� Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP►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. NOTES AND COMMENTS C,�. f- �! OCT 18 1999 _11" 7ftdF 4b s � revised 9/2/98 Pagel of11 A ;,� ✓rcied on Recycled Paper • 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM y PART A CERTIFICATION (continued) Nvp"Address: 79 Stonehorse Rd.. , osterville Jwner: E dmar d. M i l e f f Date of Inspection: /' INSPECTION SUMMARY: Check/A, 6, C, or D: A. SYS PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: . B. YSTEM 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 y s, 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 Cehificate 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 ekfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipets) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipets) 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 pipets). The system will pass inspection if(with approval of the Board of Health): broken pipets)are replaced obstruction is removed �t r revised 9/2/98 Pap 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION'Icontinued) Nop"Aaaress: 79 Stonehorse Rd. , Osterville Owner: E'd.ward. LIil¢eff 2 . , Date of Inspection: /6�/�— �y' 1 �. 12, 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 DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated.wetland or a salt marsh. i x 2) YSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER.'IF ANY)DETERMINES THAT THE SYSTEM IS NCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of 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 ic revised 9/2/98 Page 3or11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued► ca Property Address: 79 Stonehorse Rd. , osterville Owner: E'd.ward. Mileff Date of Inspection: D. S STEM FAILS You m t indicate either "Yes" or "No to each of the following: have determined that one or more of the following failure conditions exist as described 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. Yes o Backup of sewage into facility-or system component due to an overloaded or clogged SAS or cesspool. _ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. 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 112 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. E. RGE SYSTEM FAILS: You m st indicate either "Yes" or "No" 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: Ye 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 11 of a public water supply well) The net or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office f t Department for further information. revised 9/2/98 Page 4of11 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 79 Stonehorse Rd.. , Osterville Owner: Ed.ward. Mileff Date of Inspection: 16-11-Q Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: ' Yes 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-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. _ 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. I✓ _ The site was inspected for signs of breakout. _ All system components, excluding the Soil Absorption System;-have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. / The size and location of the Soil Absorption System on the site has been determined based on: v _ Existing information. For example, Plan at B.O.H. _ Determined in the field(if any of the failure criteria related' :toiPart C is at issue, approximation of distance is unacceptable) (15.302(3)(b)) - _ The facility owner (and occupants,if different from owner) were provided with information on the proper maintenanca.of SubSurface Disposal Systems. revised 9/2/98 Page 5of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION. Iroperty Address: 79 Stonehorse Rd.. , Osterville Owner: Edward. Mileff Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: g.p.d.lbedroom. Number of bedrooms(design): Number of bedrooms (actual); Total DESIGN flow Number of current residents:-9-- Garbage grinder(yes or no): A-6 Laundry Iseparate system) (yes or no):/Ld; If yes, separate.inspection required Laundry system inspected (yes or no) Seasonal use (yes or no):A,v Water meter readings,if available (last two year's usage(gpd): 1998 59 r 000 gal. Sump Pump(yes or no):Lie) 1997 60 , 000 gal. Last date of occupancy:_ ` Q/ C MMERCIAL/INDUSTRIAL: Typ of establishment: Desi n flow: qpd ( Based on 15.203) Basis of design flow Greas trap present: (yes or no)_ Indust ial Waste Holding Tank present: (yes or no) Non-s nitary waste discharged to the Title 5 system: (yes or no)_ Water eter readings,if available: Last d to of occupancy: OTH :(Describe) Last ate of occupancy: GENERAL INFORMATION PU ING RECORDS and source of information: /9 5 1'' /G �� I'a', rl,y-0�adiR System pumped as part of inspection: (yes or no) .G O If yes, volume pumped: gallons Reason for pumping: TYPE OF STEM 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. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed lif known)and source of information: •"'/ V fl ! �Of K Sewage odors detected when arriving at the site: (yes or no) d revised 9/2/98 Page 6of11 f - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 'ropertyAddress: 79 Stonehorse Rd..', Osterville , Owner: Edward. M i� f Date of Inspection: BUI ING SEWER: ' (Loca on site plan) ` Depth Blow grade:_ Materi I of construction:_cast iron_40 PVC other(explain) Distan a from private water supply well or suction line Diame r Comm nts: Ic dition of joints, venting, evidence of leakage,-etc.) SEPTIC TANK:_ (locate on site plan) Depth below grade:A) Material of construction: ✓concrete_metal_Fiberglass._Polyethylene_other(explain) „ If tank is metal,list age_ .Is.age confirmed by.Certificate of Compliance (Yes/No) Dimensions: 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: g � � Distance from bottom of scum to bottom of outlet tee or baffler How dimensions were determined: K' 'omments: (recommendation for pumping, condition of inlet and outlet tees or b ffles,depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, a c.) Id -'� A j n- K T, 3 A- " GREASE P: (locate on si plan) Depth below lrade: Material of co struction:_concrete_metal_Fiberglas's Polyethylene_other(explain) Dimensions: Scum thickne s: Distance fro top of scum to top of outlet tee or baffle: Distance fro bottom of scum to bottom of outlet tee or baffle: Date of last umping: e Comment k (recom ndation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, eviden a of leakage,etc.) revised 9/2/98 Page 7ortl SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Irop"Address:79 Stonehorse Rd. , Osterville Owner: Edward. MjlefX Date of Inspection:OD TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) (locat on site plan) Depth b low grade:_ Material f construction:_concrete_metal_Fiberglass_Polyethylene_other(explain) Dimensi ns: Capacity gallons Design ow: gallons/day Alarm p esent Alarm I vel: Alarm in working order: Yes_ No_ Date o previous pumping: Corn nts: Icon tion of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) - PUMP HAMBER:_ (locate n site plan) Pumps' working order: (Yes or No) Alarms n working order(Yes or No) Comm nts: (note ondition of pump chamber, condition of pumps and appurtenances,etc.) >11 revised 9/2/98 Page 8of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM . PART C SYSTEM INFORMATION(continued) 'rop"Address: 79 Stonehorse Rd. , Osterville Owner: Edward Mileff Date of Inspection: j6, -/S-9 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits, number:_ leaching chambers,number:.?— leaching galleries,number._ leaching trenches,number, length: leaching fields, number, dimensions: overflow cesspool,number:_ Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic fail re, level of ponding; damp soil, condition of vege ation, ) CESSPOOLS:_ (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: 4 )epth of scum layer: ) Dimensions of cesspool: _ Materials of construction: - Indication of groundwater: inflow Icesspool must be pumped as part of inspection) Com ents: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) )p ' _ ( on site plan) ls of construction; Dimensions: of solids:ents: ( ondition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) revised 9/2/98 Page 9ofII mi-Lerr Sate of Inspection: t SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) N b ` revised 9/2/98 Page10ofII it SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C `SYSTEM INFORMATION(continued) rop"Add ress: 79 Stonehorse :Rd . 0sterville Owner: Edward. ileff Date �- of Inspection:/6 d,` 9 NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited ^ Observation Wells checked Groundwater depth: Shallow Moderate ' Deep SITE EXAM Slope Surface water Check Cellar ti Shallow wells Estimated Depth to Groundwater SFeet Please indicate all the methods used to determine High Groundwater Elevation:' Obtained from Design Plans on record Observed - T Sit e A i butt n r( o er t , observation hole 9 P P Y , basement sump um etc.) Determined from local conditions (/ Checked with local Board of health _Checked FEMA Maps _Checked pumping records Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) M t revised 9/2/98 Page uoru f i B� THE COMMONWEALTH OF MASSACHUSETTS BOARD JOF HEALTH 1 011 ..I OF........../�d9�7ltif L.6C r..........................--------I Appliration -filar Mapaaat Works Towitrurtiou Vrrmit Application is hereby made fora Permit to Construct ( ) or Repair ( } an Individual Sewage Disposal System at: � .0ke ......... r.................................................fo/"sv�fly - ----t - --------/----- -- Location-Address or L f No. L.l k/..........f 1 �-['............................ ------------------ ---- --------------------------------------------- Owner Address ,Wl -•-•----•---......-E�• vlA. 19.f9. ...I.-----•.................. ........................................... Installer Address Q Type of Building Size Lot____________________________Sq. feet U Dwelling—No. of Bedrooms-----3-----------------------------------Expansion Attic ( ) Garbage Grinder ( ) pi Other—Type of Building ............................ No. of persons..................._----_. ( ) ( ) ._ Showers — Cafeteria Q' Other fi�.tures ----------------------------------------------------------- ---------- W Design Flow-------------- __v............_........_gallons per person per day. Total daily flow----------------------------------.---------gallons. WSeptic Tank—Liquid capacity a-gallons Length----------------- Width................ Diameter---------------- Depth.---------...... x Disposal Trench—No.--------------------- Width.................... Total Length-------------------- Total leaching area-.-.-.-._-.-_----.-sq. ft. Seepage Pit No-----/_O60--- Diameter.................... Depth below inlet.................... Total leaching area------------------sq. It. z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by--------------............................................................ Date--------------------------------------- ,� Test Pit No. 1----------------minutes per inch Depth of "Pest Pit-------------------- Depth to ground water__..-_--------.--.-..._. �14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water--.---------.----__--__. 9 --------------------------------------------------------------------------------------------------------•---------------------------------------•------------ 0 Description of Soil---------------------------------- ep U ---------------------------------Jly ...... G' ..........f°--��---------------------------------------------------------------------------------------- x •- U Nature of Repairs or Alterations—Answer when applicable..---------------------------------------------------------------------------------------------- -------------------------------------------------------- --------------------------=----------------------------------------------------------------- ------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Se wa e Disposal System in accordance with the provisions of Article NI of the State Sanitary Code—The undersigned f ther agrees not to place the system in operation until a Certificate of Compliance has been issued by the bo f h lth. Signed-------- •... -----•• --• -- ---- ------------- -- -- ----- ----------------- -------... Date Application Approved By------------------------------------------------------- -------------- - ,� � Date ' Application Disapproved for the following reasons:------------!-------___..-------------- _ - +2___ ......_...•-••-----...---•--_---•-•=--•-------------------------•--------- Date PermitNo. --�-9-----------•---•--•---...... Issued...................... ................................. Date Fmic............................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........0 F..........A01WJr If Z, 6...... ............................ .......................... .......... Appliration -for :41-4poiial Vorkii Tonstrurtion Prriftit Applicia,fion is hereby made for-a Permit to Construct or Repair an Individual SbNUge Disposal System at: A0*j .. . ............................................. Locatto ' -.-.--------- ..... .... ............-.--.... - Ad ;� - -------------o r---L-o-- - 0. .................h_40.4e .........J) . ..ram........... ........... . 0 ------------------------------------------ Address ........... .......................... .................................................................................................. Installer Address 1:11 Type.-of Building Size Lot----------------------------Sq. feet J Garbage Grinder Dwelling No..of Bedroomq-----3------------------------------------Expansion Attic G, -1 N '-sons-----------_-----------*---- Showers Cafeteria - - . ---------- 0-4 jeT pe ltilil_�y 44 Other fi3,tures ------------------------------------------------------ --------------------------------- ----------------------------------------------------------- Design,.,FflodVli.�,il;,�l.t;k-i"..,.-j--- --gallons per person per day. Total daily flow---------------------_-_-_---.---. .-- -.gallons. Liqtli'a-iff�p,tc,itv/Off--�--gallons Length................ Width.-----...------- Diameter_------------- Depth. ...----------- Disposal ii�ch—No. ""�Xfidtli.................... Total Length-.--._------------.- Total leaching area..--..--------------sq. f t. Seepage Pit No Dimeter-------------------- Depth below inlet--......._.......... Total leaching g area------- ------ S(l. It. *----x6a----- a - . . Z Other.Distribution box Dosing tank Percolation Test Results Peif'o'rmed by.---------------- ........................................................ Date---------------------------------------- 0-1 Test Pit No. I................minutes per inch Depth of Test Pit..---.........--.--. Depth to ground water.---------------_------ (� Test Pit No. 21�.,_........-__minutes per inch Depth of Test Pit-------------------- Depth to ground water.-.--.------_--._..__. O Description of Soil----------- -------- x - .......e..................lt�W)�___----------I-------------------------------------------------------------------- ----------------------------------J, ,A W.- ...------- ........................... .......--------------------------------------------------------------------------------------- U ------------------------ ---------------P------------------------------------------------------------------------------------------------------------------------------------------ U Nature of Repairs or Alterations—Answer when applicable---------------------------------------------------------------------------------- ------------- ----------------------------------------------------- ------------------------------------------------------- ------------------------------------------------------------------------------------------ Agreement: The undersigned agrees to install the aforedescribed Individual SewaejDisposal System in accordance with n the provisions of Article XI of the State Sanitary',Code, �eVndersig'ed f ther agrees not to place the system in operation until a Certificate bf'C_6K6114_1_ 'h is planfl,e?, as, been the b h Ith. Signed-------- .... .... . ..... ................. ... ..... -------------------------------- Date ApplicationApproved"hy-----------------------------------------------I_,------------------------------------------------- ----------------------------------------- Date Application Disapproved for the following reasons:--------------------------------------------------------------------------------------............................. --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Date 7 `..............I...... Permit No.......... ... ................ Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............. .......... . ..... .7" ............................ Tntifirate of Trrmviiaurr THIS IS TO C TIFY, T1 hc Individual Sewage Disposal System constructed or Repaired g ...... -----.................... ...........................................................by...........................4 ....... ii -------------------------------------- . ...........I. .. ....... Insta1_1er -C , — ------------- . . .... . . ................ ......... ........ -------- at.................� ............&----------- has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.......................................... dated._..----------------..-.....-----_---........... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.-.-..*............................................................................ Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF7HEALTH 71... ...........to .........OF.... No.._.._.... ........................... FEE---- ................... Binvo5al IT iitrur ion Prrmit Permissionis hereby granted------- --- ------ ----------- ............................................................................................................ to ConstructEt R at J or Repair an1 ndivjaal SewageD41al System - --- ------ ----- No...... ......... ...... ....................... . ...... ------- ----- --- ---- Street as shown on the application for Disposal Works Construction Permit No.;1 Dated-- ... ........... . - -- --------------------------- Boar f Health I DATE.= ------------ ---------------------------------- ---- - -- --- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS i 0 7 O • i�, ZD �32tr- L