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HomeMy WebLinkAbout0215 TANGLEWOOD DRIVE - Health 215 Tanglewood Drive, Osterville 121 - 086 0 I i I I °• i 6 1 f �Z TOWN OF BARNSTABLE LOCATION i S � �w��� ; SEWAGE # 9J /7''�� VILLAGE— ®,� � 11 ASSESSOR'S MAP & LOT a O� INSTALLER'S NAME&PHONE NO. 0 bol SEPTIC TANK CAPACITY ��. J LEACHING FACILITY: (type) 3':/4!:2-0' --JE, (size) /'0—al d"2— NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE:�Ao-3--1� COMPLIANCE DATE: ld Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by old r I i VL i M a No. �"� � Fee $5 0 .0 n THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pplication for Migozaf *pgtem Construction Permit Application for a Permit to Construct( )Repair(X4 Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 215 Tang 1 ewood Dr Owner's Name,Address and Tel.No. 4 2 8—2 8 6 9 Assessor'sMap/Parcel o`terville MA Arthur Cullinan 6 Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No. Wm E Robinson Sr Sept Sry PO Box 1089 Centerville MA 026 2 Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder(no) 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) T i i-1 P 5 L e a ch i ng a—t i Gn consisting of new D—box, and three H-20 stonepackPd infiltrators 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 oar f Health. Signed 1 '' Date�� Application Approved by f (. Date Application Disapproved for the following reasons Permit No. Date Issued No. _ Fee $5 0. T.� 4 THECO'MMONWEALTH OF MASSACHUSETTS Entered in computer: _ - PUBLIC HEALTH.DIVISION -TOWN OP BARNSTABLE., MASSACHUSETTS Yes Z,[pprication for 3Digool 6pelem Construction Permit Application for a Permit to Construct( )Repair(x�Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 215 Tanglewood Dr Owner's Name,Address and Tel.No. 428-2869 Assessor'sMap/Parcel Osterville MA Arthur Cullinan ' Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 775-8776 Wm E Robinson Sr Sept Sry PO Box 1089 , Centerville, ma n2"2 Type of Building: Dwelling No.of Bedrooms 3 � Lot Size sq. ft. Garbage Grinder(no) Other Type of Building : f No.of Persons Showers( ) Cafeteria( ) Other Fixtures f Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title r Size of Septic Tank Type of S.A.S. Description of Soil sand r ; Nature of Repairs or Alterations(Answer when applicable) Title 5 Leaching . ativu R consisting of new D—box and three--H 20 stonepaeked. : fi1 tors. Date last inspected: Agreement: r 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 Boar f Health. a Signed C•i f d Date/U _3`(i Application Approved by Date Ay— L- Application Disapproved for the following reasons. Permit No. 4 -- , Date Issued , -------------- — `/ --------------------- ', / Cry✓'' TH�=MMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Cullinan Certificate of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired(xx)Upgraded( ) Abandoned( )by Wm E Robi nsnnSgr ,Sept Sry at 215 Tanalewood D has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. ated�/ Installer Wm E Robinson sr S,P=t $r j, Designer The issuance of this permit sh 11 no be c strued as a guarantee that the s�CsteutV11unctr'on as deigned. Date � V Inspector /i�. D l --- No. �- —-------------------------Feed THE COMMONWEALTH OF MASSACHUSETTS - PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS / Cullinan 'Wi5po5ar *pgtem Con%truction Permit Permission is hereby granted to Construct( )Repair(x})Upgrade( )'Abandon( ) System located at 2J 5 Tangleweed Dr ��lt�� 9f ��t E6='{ 1 1 �,g�i""' i n n Sept Sry � InInstaller: WM W .R. Rnh en Sr 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 it. Date: Approved by<!�� � t I ti NOTICE: This form 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. Robinson, Sr. ,hereby certify that the application for disposal works construction permit signed by me dated 16 ,3-9 `7 , concerning the property located at 215 Tanglewood Drive, Osterville. MA meets all of the following criteria: * There are no wetlands within 300 feet of the proposed septic system. * There are no private wells within 150 feet of the proposed septic system. * The obseved groundwater table is 14 feet or greater below the bottom of the leaching facility. * There is no increase in flow and/or change in use proposed. * There are no variances requested or needed. SIGNED: 6J l DATE Zd - LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER 60 (Attach a sketch plan of the proposed system. Also if the licensed installer proposes a certification plot plan,this plan should be submitted). V °'A- 1 TOWN OF BARNSTABLE ov a o Z SEWAGE # .S 7 1 LOCATION i S / `` �G(J _ ASSESSOR'S MAP & LOT OCR VI LLAGE _ INSTALLER'S NAME•&PHONE NO. SEPTIC TANK.CAPACITY S LEACHING FACILITY: (type) ':.� a'/►-Iv (size) NO.OF BEDROOMS BUILDER OR OWNER A/d ' , PERMIT DATE:��U—,' Z—COMPLIANCE DATE: I- Separation Distance Between the: Feet Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Private Water Supply Well and Leaching Facility (If any wells exist Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) Furnished by 3 d M � II • ,per .\ COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFA-IRS- " DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET. BOSTON, MA 02108 617 292-�500 OCT 2' WILLIAM F.WELD 1997 TRUDY CORE GovernorIUiNN 0E BARAi Secre �' H�+(TNOEPLABIE DA1. B.STRUHS ARGEO PAUL CELLUCCI Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION Commissioner PART A L t, CERTIFICATION Property Address: 215 Tanglewood Dr, Ostervi 1 le Address of Owner: Arthur Cullinan Date of Inspection: /10 - S—g 171 1 (If different) Name of Inspector: Wm E Robinson Sr I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name:, Wm E Robinson Septic Service Mailing Address: PO Box 1089 , Cent-erpi' 1 1 a. MA 02632 Telephone Numbed 5 0 8^ 7 71,_R 7 7 6 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: (,asses _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: Lv o Date: ZD 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 below. COMMENTS: 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 exfiltration, 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 04/25/97) Page 1 of 10 DEP on the World Wide Web: http:ltwww.magnet.state.ma.us/dep 0 Printed on Recycled Paper all SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 215 Tanglewood Dr, Osterville Owner: Arthur Cullinan Date of Inspection: !©—F-1 - B) STEM 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 C) URTHER 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 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 a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT 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 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 waver 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 (revised 04/25/97) Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 215 Tanglewood Dr, Osterville Owner: Arthur Cullinan Date of Inspection: 16_7- 9 7 D] SYSTEM FAILS: You must indicate ei:t,er "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 necessary to correct the failure. Yes No 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— q 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] LARGE YSTEM FAILS: ' You must r dicate either "Yes" or "No" as to each of the following: T e#following criteria apply to large systems in addition to the criteria above: T e system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to ublic 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 II of a public water supply well) The ow er or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program require ents of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04/25/97) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 215 Tanglewood Dr, Osterville Owner: Arthur Cullinan Date of Inspection:`® ��7 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. _ 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. q / 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. 1! _ 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)] a Jj (raviaad 04/25/97) Page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 215 Tanglewood Dr, Osterville Owner: Arthur Cullinan Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow:411F0 .p.d./bedroom for S.A.S. Number of bedrooms: Number of current residents: Garbage grinder (yes or no): �, o Laundry connected to system (yes or no) i7 Seasonal use (yes or no):,- Water meter readings, if available (last two (2) year usage (gpd): 1995 - 5 4 0 0 0 ga 1 s Sump Pump (yes or no): A,0 1996 - 64, 000gals Last date of occupancy:16 9 COMMERCIALA N D USTRIAL: Type of establishment: Design flow:_gallons/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:' r GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no)-,Lil� If yes, volume pumped: gallons Reason for pumping: TYP&. O XYSTEM V 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: /0'-�5`mac i Sewage odors detected'when arriving at the site: (yes or noA�) revised 04 45 97 Page 5 of 10 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: D.•- (` /f BU ING SEWER: (Locate on site plan) Depth low grade: Material of construction: _cast iron _40 PVC_other (explain) Dista a from private water supply well or suction line Diame r Comm nts: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK:_ (locate on site plan) Depth below grade: Material of construction: ��oncrete _metal _Fiberglass _Polyethylene —other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No) Dimensions: G Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: 3 ' 1, Distance from top of scum to top of outlet tee or baffle:_ Distance from bottom of scum to bottom of outlet tee or baffle:'�i How dimensions were determined: 6 IF4f - 74 Comments: (recommendation for pumping, condition of inlet and outlet tees or baffle , depth of liquid lev in relation to outlet invert, structural integrity, evidence of leakage, etc.) v GREASE RAP: (locate on site plan) Depth low grade: Ma,eri1 of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain) Dime sions: Scu thickness: Dis ace from top of scum to top of outlet tee or baffle: Distan from bottom of scum to bottom of outlet tee or baffle: Date of st pumping: Commen s: (recom ndation 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.) (revimed 04/25/97) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 215 Tanglewood Dr, Osterville Owner: Arthur Cullinan Date of Inspection: /a-9--7 TI HT OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection) (lo a on site plan) Depth low grade: Materia of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain) Dime ions: Capa rty: gallons Des' n flow: gallons/day Alar level: Alarm in working order_Yes; _ No Date o previous pumping: Comme ts. (conditi n 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 AMBER:_ (locate on ite plan) Pumps in w rking order: (Yes or No) Alarms in Irking order (Yes or No) Comments (note con ition of pump chamber, condition of pumps and appurtenances, etc.) (revised 04/25/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 215 Tanglewood Dr, Osterville Owner: Arthur Cullinan Date of Inspection: 16-9-4 -7 / 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. 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 9f hydraulic failure_ o�t level of pon cg, condition of ve etatio)r, etc.) aI CESS OOLS: _ (locate n site plan) Number d configuration: Depth-top of liquid to inlet invert: Depth of s lids layer: Depth of s um layer: Dimension of cesspool: Materials - construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Comm en (note con 'tion of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: (locate on ite plan) Materials f construction: Dimensions: Depth of s ids Comments: (note conditi n of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 04/25/97) Page 8 of 10 � y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 215 Tanglewood Dr, Osterville Owner: Arthur Cullinan Date of Inspection: /0-- g--$ 17 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) 1 , bC f� P..0 d 1 I (revised 04/25/97) Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 215 Tanglewood Dr, Osterville Owner: Arthur Cullinan Date of Inspection: 9-5 -7 2K Depth to Groundwater`( Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record V/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 Use USGS Data Describe in your own words how you established the High Groundwater Elevation. (Must be completed) Aek (revised 04/25/97) Page 10 of 10 No................�....... - F�s......1 ` J` .. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF77 HEALTH ------- --------_ .....----...--OF.......... /:.-... ' _.._...-... .....-...... Applira#ion for Dispniial Workii Tuntitrnrtinn Famit V/ Application is hereby made for a Permit to Construct (K�or Repair ( ) an Individual Sewage Disposal System at: / r9n' 1e- 4.o e �� �2t v -eU, ...... - --T .....-............................................................. .................... T ...... .. .._.....-- - ocation-Address / or Lot o. f�...�... ........&.....-•- ... rl--:_.( B.�r� . . .�5........�. .1?'..3:........Cl.. .........................../iv1c c P Ow r _ Address �/-•...... .. .!.......... ��� e s =-........i6-s��N.s.T� g a a Installer Address UType of Building Size Lot.. f. _.._o...Sq. feet 4 Dwelling! No. of Bedrooms......... ..............................Expansion Attic ( ) Garbage Grinder (ram aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures ................................. ------------------------ ----------- W Design Flow.........&-.5...........................gallons per person per day. Total daily flow......J. IA;2..._•.................__gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................ Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No_____________________ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Other Distribution box ( ) Dosing tank ( ) �> 06� . -7— Z-/`' 7- Percolation Test Results Performed by_._-� �� - ..� � Date a , �- 14 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_. f > r --Description o.. Soil. . z - I -- - --------- ....... - --------------------------.......-••-•-_......•--•------------•-.......---•----•••---•-- ...............................................W •-••------•--------•---------•-•••-------------•-•-••-•----•----•--•------••••••-••-•--•------•••-•-------••-•-•-----•------••......---••-••--- f 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 TITIE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be` issu d,by th board of health. Signd-----. ... ........... :.� ................................ _ ..... . Date Application Approved BY �!•d=.Gl l�'f c'=-------------•------- -- •. ........-7----- f-' Date Application Disapproved for the following reasons:.................................. ••-------•..............•-••-............................ ............- ....---•------•------------------•--------•--•--••-•-------.....-=--------------••-------•-••-------------------------•-------•-------------•-•-•••-•--- ............................................... ,L —1 7 Date Permit No....................................................... Issued.... .. Date , �r No................ ....... THE COMMONWEALTH OF MASSACHUSETTS `E BOARD OFI. HEALTH �. ............... ... .-.. ..OF...........IoiOo ".. :...... Appliration for.UhiposFal Works Tonotrurtion rrmi# Application is hereby made for,.a Permit to Construct ( 115 or Repair ( ) an Individual Sewage_Disposal System at ..... • .._... _...... ..- .. ..................... ..........•-..... ........................ ------•_ ---....._......------ -•--...............•. -" ! 4 f�'ocation-Address - or Lot No. / • _,.) fi— a: .... ................. .......... ...... Ow r Address a .....................................-•--••----• . •--•-•--------- ----- Installer Address Type of Buildin Size Lot__ -p'�_4. Q_: qfeet Dwelling—No. of Bedrooms.......... .............................Expansion Attic ( ) Garbage Grinder (oOXO '4 Other.—Type of Building ............................ No, of persons____________________________ Showers — Cafeteria P4 Other fi ures --•-------••--- -•---••--••••-- . W Design Flow..........6_.:...........................gallons per person per day. Total daily flow....... ._, . ........................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.................... Depth below let__ �...... Total leacl}ing�ar..................sq. ft. Z Other Distribution box ( ) Dosing to ( ) V ' 2 i ~ �. Percolation Test Results Performed by.'*: 1 l �:............. ......... Date_.; .7-2-��.... ...._._. ,.� Test Pit No. 1...r�,... _._minutes per inch Depth of Test Pit.................... Depth to ground water.._..........._......:-. (i Test Pit No. 2................minutes per inch. Depth of Test Pit.................... Depth'to ground water........................ } ... O Description of Soil 4 . ! - r ----- - 1 'Glow' U ----------------•----------------- = = = ---------------------------------------------------------------------------------------------------•--------------------......------------------............-------------------------------------------- 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 TIT - 5 of the State Sanitary Code— The undersigned further agrees not to place the system_ in operation until a Certificate of Compliance has be ssli d by th board of health. Sign . ..... _.... to Application Approved BY----.--- ......... ----- ........ ... ...... ,r =-------------• ....#7..•_,_� .-..� ��I����'�11iy��` 'Date Application Disapproved for the following reasons------------------------•---------------------------------------------------------------•--. ---•-•--••-----•--. --------------------------------------------•----------------------•------.........._---------------...-- Date Permit No........................ Issued- = Date THE COMMONWEALTH OF MASSACHUSETTS • BOARD OF HEALTH .............. ....................OF..........X.041.4-4-.-I....................................... Tntif iratr of Tompliaurr THIS TO CERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( ) r by f: •- ..............`'l -'..-----_.... j stal has been installed in accordance wi 1 the provisions of T r of The State Sanitary Code as de cribed in the application for Disposal Works Construction Permit No :. "*�._..._._. dated_---__ _ow" .. '' % ...... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM ,WIL:, FUN ION SATISFACTORY. DATE. — < Inspector................................... f L THE COMMONWEALTH OF MASSACHUSETTS BOARD O " HEALTH OF...... ... 4 . / l � No......... ...........: FEE... ...•--••- r Dispar at Permission • reby granted_ .. .. ` pay a di ua( ) I vidh to Constr or Re e Disp. S s Street -7 as shown on the application for Disposal Works:Construction P o.._..__ ated....7...�:f .......... -------------- ----' Board of Health DATE = FORM 1255 HOBBS�&'WARREN. INC.. PUBLISHERS 7•a - -y-- - r � n, iLy Mary = Rio r 33G WD __------ r r irU %?d'T" `". /�©4�' tT."•Y.� � �t 51a' (RiV ; NWr,�,� {_ Go?' .zG 5IPG l3U�fC.�rcJG r �o�A! Qe�S/GN 7-1:Jr WILLIAM C. A' . �a N y ENo rtr �? 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