HomeMy WebLinkAbout0263 TOWER HILL ROAD - Health 263 TOWER HILL ROAD, OSTERVILLE
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TOWN OF BAR44STABLE
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� �i 10 SEWAGE #
VILLAGE VS �� — ASSESSOR'S MAP& LOT '
INSTALLER'S NAME&PHONE NO. TT
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) EMS� (size)
NO.OF BEDROOMS
BUII.DER OR OWNER lS�
PERMPTDATE: COMPLIANCE DA .
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 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) �a Feet
Furnished by
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Conunonwealth of Massachusetts
Executive Office of Enviroiunental Affairs
Dept. of Environmental Protection
One winter Street,Boston,Ma. 02108 .To ,
DRP " 411 ®pt c Ins ctor
Box 2119
atic et, VlA 02536�'a�
WILLIAMF.WELD (5Govemor
04E�J�'t3 "
I
ARGEO PAUL CELLUCCI OCT 5 1998
t.Governor +..
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM TOWN OFBARNSTABLE
HEALTH DEPT
PART A
CERTIFICATION
-v
Property Address: 263 TOWER HILL RD.OSTERVILLE MAP 118 PAR 94 Address of Owner:
Date of Inspection: 9/23/98 (If different)
Name of Inspector: JOHN GRACI EDISON MARNEY:199 PRINCE AV.MARSTONS MILLS
I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000)
Company Name,Address and Telephone Number:
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:
X_ Passes This Inspectlon Is based on criteria defined In Title V
_ Condition Pa5565 code310CIAR16.303.My findings are of how the system is
y performing at the time of the inspection.My inspection does
_ Needs F h Evaluation By the Local Approving Authority not Imply any warranty or guarantee of the longevity of the
Falls septic system and any of Its components useful life.
Inspector's Signature: Date: 9129198
The System Inspector shall s bmit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspections. 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:
x I have not found any information which indicates that the system violates any of the failure criteria
defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below.
COMMENTS:
B] SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system,upon completion
of the replacement or repair,passes inspection.
Indicate yes, 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 04127)97)
One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 o Telephone(617)292-5500
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Add ress: 263 TOWER HILL RD.OSTERVILLE MAP 118 PAR 94
Owner: EDISON MARNEY:199 PRINCE AV.MARSTONS MILLS
Date of Inspection:9123199
_ Sewage backur)or.hreakoutor high.static water level observed.in.the distribution box is due to a broken.
or obstructed pipe(s)or due to 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 leveled 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] 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 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 PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 feet to a
surface of water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and 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 presense of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method usedto determine distance (approximation not valid)
3)Other
D] 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 necessary to correct the failure.
Yes No
Backup of sewage in facility or system component due to an overloaded or clogged SAS or
cesspool.
Di9charge.or ponding of effluent to the surface of the ground or surface waters due to an owerloa(led or rlogge.d
cesspool.
SAS is in hydraulic failure.
(revised 04127)97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
s .
Property Address: 263 TOWER HILL RD.OSTERYILLE MAP 118 PAR 94
Owner: EDISON MARNEY:109 PRINCE".MARSTONS MILLS
Date of Inspection:9123199
D] SYSTEM FAILS(continued)
Yes No
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).
Numbers 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 1 of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. 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 SYSTEM FAILS:
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:
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 II of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 04127)97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECLIST
Property Address: 263 TOWER HILL RD.OSTERVILLE MAP 119 PAR 94
Owner: EDISON MARNEY:199 PRINCE AV.MARSTONS MILLS
Date of Inspection:9123199
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
_c_ — Pumping information was requested of the owner, occupant,and Board of Health.
x None of the system components have been pumped for at least two weeks and the 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.
x As built plans have been obtained and examined. Note if they are not available with N/A.
x — The facility or dwelling was inspected for signs of sewage back-up.
x _ The system does not receive non-sanitary or industrial waste flow.
—x— — The site was inspected for signs of breakout.
x All system components, excluding the Soil Absorption System, have been located on the site.
x 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.
x _ 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 Systens.
x Existing information. Ex. Plan at B.O.H.
x Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is
— — unacceptable)[15.302(3)(b))
(revlsed 04127)97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM'
PART C
SYSTEM INFORMATION
Property Address: 283 TOWER HILL RD.OSTERVILLE MAP 118 PAR 94
Owner: EDISON MARNEY:199 PRINCE AV.MARSTONS MILLS
Date of Inspection:9123199
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 330 g•p.d./bedroom for S.A.S.
Number of bedrooms: 3
Number of current residents: 2
Garbage grinder(yes or no): No
Laundry connected to system(yes or no): Yes
Seasonal use(yes or no): No
Water meter readings, if available:(last two(2)year usage(gpd):
nla
Sump Pump(yes or no): No
Last date of occupancy: nla
COMMERCIAL/INDUSTRIAL:
Type of establishment: nla
Design flow:o gallons/day
Grease trap present: (yes or no) No
Industrial Waste Holding Tank present:(yes or no) No
Non-sanitary waste discharged to the Title 5 system:(yes or no) No
Water meter readings,if available: nfa
Last date of occupancy: nla
OTHER: (Describe) nfa
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
nfa
System pumped as part of inspection: (yes or no)No
If yes,volume pumped:0 gallons
Reason for pumping: nfa
TYPE OF SYSTEM
x Septic tank/distribution box/soil absorptions 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 Information:
1984 BY TOWN HALL ASBUILT
Sewage odors detected when arriving at the site:(yes or no) No
(revleed 04r17)97)
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 263 TOWER HILL RD.OSTERVILLE MAP 118 PAR94
Owner: EDISON MARNEY:190 PRINCE AV.MARSTONS MILLS
Date of Inspection:9123198
SEPTIC TANK: x
(locate on site plan)
Depth below grade: 2'
Material of construction:x concreate metal FRP Polyethylene_other(explain)
If tank is metal, list age nIa . Is age confirmed by Certificate of Compliance No (Yes/No)
Dimensions: L8'6"H5'7"W4'10"
Sludge depth:2"
Distance from top of sludge to bottom of outlet tee or baffle: 32"
Scum thickness:1"
Distance from top of scum to top of outlet tee or baffle:S"
Distance form bottom of scum to bottom of outlet tee or baffle: 17"
How dimensions were determined: MEASURED
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.)
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING EVERY ONE TO TWO YEARS.
GREASE TRAP:_
(locate on site plan)
Depth below grade: rda
Material of construction: _concrete_metal_FRP_Polyethylene_other(explain)
Dimensions: rda
Scum thickness:rVa
Distance from top of scum to top of outlet tee or baffle:rva
Distance from bottom of scum to bottom of outlet tee or baffle:Na
Date of last pumpingn*
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.)
rda
BUILDING SEWER:
(Locate on srte plan)
Depth below grade: 2-6"
Material of construction:_cast iron x 40 PVC_other(explain)
Distance from private water supply well or suction IineTOWN
Diameter: nIa_
greimments: (conditions of joints,venting,evidence of leakage, etc.)
(revleed 0427197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 263 TOWER HILL RD.OSTERVILLE MAP 778 PAR94
Owner: EDISON MARNEY:199 PRINCE AV.MARSTONS MILLS
Date of Inspection:9123199
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade: rva
Material of construction:_concrete_metal_FRP_Polyethylene—other(explain)
Dimensions: era
Capacity: rda gallons
Design flow: rda gallons/day
Alarm level:_nra Alarm in working order?_Yes_No
Date of previous pumping:
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
Na
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert: n1a
Comments:
(note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box etc.)
rda
PUMP CHAMBER:Yes
(locate on site plan)
Pumps in working order:(yes or no)No
Alarms in working order(yes or no)_Yes
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
rda
)rsylsed 0412D97)
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 263 TOWER HILL RD.OSTERVILLE MAP 118 PAR 94
Owner: EDISON MARNEY:100 PRINCE AV.MARSTONS MILLS
Date of Inspection:9123198
SOIL ABSORPTION SYSTEM (SAS):x
(locate on site plan, if possible;excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present,explain:
nra
Type:
leaching pits,number: 1000 GALLON LEACH Prr
leaching chambers,number:nra
leaching galleries,number: rda
leaching trenches, number,length: nra
leaching fields, number, dimensions:rda
overflow cesspool, number:nra
Alternate system: nra Name of Technology:_nra
Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
THE LEACH PIT IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY,THE PIT WAS 314FULL AT THE TIME OF THE INSPECTION.
CESSPOOLS:
(locate on site plan)
Number and configuration: rda
Depth-top of liquid to inlet invert: nra
Depth of solids layer: nra
Depth of scum layer: rda
Dimensions of cesspool: nra
Materials of construction: nra
Indication of groundwater: nra
inflow(cesspool must be pumped as part of inspection)
nfa
Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
nra
PRIVY:_
(locate on site plan)
Materials of construction: nra Dimensions: rda
Depth of solids: nra
Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.).
nra
treylaed 04127197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
263 TOWER HILL RD.OSTERVILLE MAP 118 PAR 94
EDISON MARNEY:199 PRINCE AV.MARSTONS MILLS
9123l98
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)
01 Fe c)1
(revmedO4R7197) Page t of to
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
263 TOWER HILL RD.OSTERVILLE MAP 119 PAR 94
EDISON MARNEY:199 PRINCE AV.MARSTONS MILLS
9123198
Depth of groundwater o
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
Cheek pumping records
Check local excavators, installers
x Use USGS Data
Describe in your own words how you established the High Groundwater Elevation.(MUST be completed)
GROUND WATER FOR LEACH PIT IS 12+FEET
(revIsed0427197) page 10 of 10
Nr . w
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE,OF ENVIRONMENTAL AFFAIRS
W
+ DEPARTMENT OF ENVIRONMENTAL PROTECTION
SOUTHEAST REGIONAL OFFICE
V
ARGEO PAUL CELLUCCI TRUDY COXE
Governor Secretary
DAVID B.STRUHS
Commissioner
NOV 2 5 1998-
DATE.: Municipality:. BARNSTABLE
RE: NOTIFICATION OF WETLANDS PROTECTION ACT FILE NUMBER
The Department of Environmental Protection has received a Notice of Intent filed in
accordance with the Wetlands Protection Act (M.G.L. c.131, §40) :
Applicant: Nancy Schroeder & Donald Yunker
Project Location: 263 Tower Hill Road (Assessor's 118, Parcel 94) .
Please submit the below additional required information and . include your assigned file
number on all correspondence.
r:( _
( ) Proof-of abutter notification pursuant to M.G.L. c. 472 of the Acts of 1993.
( -) Stormwater management form
Comments
This project has been assigned the following file #: SE 3-3451'
ISSUANCE OF A FILE NUMBER INDICATES ONLY- COMPLETENESS OF SUBMITTAL,'
NOT APPROVAL OF APPLICATION
For more information please contact: Angela DaCosta (508) 946-2745
(X ) PLEASE SEE OTHER SIDE FOR POTENTIAL ADDITIONAL APPLICABLE REQUIREMENTS
CC: Conservation Commission
,/(,X) Board ,of Health
(X) U.S. Army Corps of Engineers
( ) Mass. Division of Marine 'Fisheries
( ) DWW - Boston - ATTN Judy Perry
( ) -U.S,-.E.P.A':'A= Region 1 _ r 1 - '� �s
(X) DEP SERO BRP - ATTN: Ron Potter
fit.. 1_
20 Riverside Drive'* Lakeville, Massachusetts 02347 • FAX (508) 947-6557 • Telephone .(508) 946-2700
This information is available in alternate format by calling our ADA Coordinator at (617) 574-6872.`
DEP on the World Wide Web: http:/hwww.magnetstate.ma.usldep
�RI�Printed on Recycled Paper
IF CHECKED, THE FOLLOWING ITEM(S) APPLY TO THIS NOTICE OF INTENT: .
( ) Please send copy of Notice of Intent and Plans to Massachusetts Division of Marine
Fisheries, ATTN: Sports Fisheries Biologist at 50A Portside Drive, Pocasset, MA or if
Nantucket or Martha's Vineyard to MDMF, ATTN: Greg Skomal at P.O. Box 68, Vineyard
Haven, MA 02568.
X Other Regulatory Jurisdiction
(X) Chapter 91 license may be required. Please complete enclosed application and submit
to this office or provide information why .license is not required.
(X) Applicant is advised to forward a copy of the Notice of Intent to the Corps of
Engineers for review (call 1-800-362-4367 for information) .
( ) Applicant is advised to contact U.S. . Environmental Protection Agency at (617) 565-
3909 regarding need for Stormwater permit.
401 Water Quality Certification (314 CMR 9.00) .may be,required. See below for
further details:
( ) .Based upon the information submitted in and with your Notice of Intent a separate
401 Water Quality Certification application form is not required. Provided that the
project meets the following conditions, summarized below from- 310 CMR 9.03 and 9.04, and
the conditions under the Corps of Engineers Programmatic General Permit for Massachusetts
(PGP) , the project qualifies for 401 Certification as certified under the PGP:
(a) activities are conducted in compliance. with MGL ,c.131, . §40 (the Wetlands Protection
Act) and the Final Order of Conditions permitting the activities does not result in
the loss of more than 5,000 square feet cumulatively of bordering and isolated
vegetated wetlands and Land Under Water and/or the.dredging of more than 100 cubic
yards of Land Under Water;
(b) the Final Order of Conditions requires' at least 1:1 replacement of 'Bordering
Vegetated Wetlands pursuant to 310 CMR_ 10.55 (4) (b) ;
(c) The project is not listed in',314 CMR 9.04(1) through (11) including: discharge of
dredged or fill material to any Outstanding Resource Water; any' part .of a
subdivision unless deed restricted, so• long as the discharge is not to an
Outstanding Resource Water see 314 CMR 9.04 (3) ; activities.exempt from MGL c.131, .
§40 (except for normal maintenance and improvement of land in agricultural or
aquacultural use) ; discharge of dredged or fill material to an isolated vegetated
wetland identified as rare and endangered species habitat; loss of any salt marsh;
activities subject to an- individual 404 permit.
Information and a copy of the PGP can be obtained from the Corps of Engineers at 1-
800-362-4367. If impacts to resource areas or project size increases beyond that
described in the Notice of Intent or there are discrepancies therein, you must
notify the Department and request a determination that the criteria of 310 CMR 9.03
have been met before the activity may begin.
( ) Before the activity described in the Notice of Intent can commence, you must obtain a
Water Quality Certification from this Regional Office Please complete the enclosed 401
Water Quality Certification application form and file it with this Regional Office for
review.
( ) Your project involves dredging of greater than 100 cubic yards of-Land Under Water.
Please complete the enclosed 401 Water Quality Certification application form and submit
.to the Department of. Environmental Protection, Waterways Regulation Program, One Winter
Street, Boston, MA 02108. Call the Waterways Regulation Program at 617-292-5695 with any -
questions.
fnum.abb
J
LOCATION SEWAGE PERMIT NO.
VILLAGE
I N S T A LLE 'S NCE i ADDRESS
f 7 �
BUILDER OR OWNER
' DATE PERMIT ISSUED 'r _).o . ef
DATE COMPLIANCE ISSUED & t. 147
6.,, ,_
v` 16 �4 _
No.. ...1...: � �. Fss. , ..._............._
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
...----....................................O F..........................................-----------........--------._._.................
ApplirFa#ion for UWpaii al Vorko Tomitrnrtiun F amit
Application is hereby made for a Permit to Construct ( ) or-Repair ( ) an Individual Sewage Disposal
System at
. ...:.. lad .................... �1� -----•--- ------•------------•--------------••-•----. ---•••------••-•-••-•--------............
-•-
Location- r or Lot No.
....._ . _ �.A- -• --1��....... . ........................................................
�h�
Owner Address
a 107
% ��........................•............. ........ ------........-•--•-•------------••--•---........................•-•---------
Installer Address
Type of Building Size Lot_-_--______•----------------Sq. feet
U Dwelling—No. of Bedrooms.....................•.......... .__..Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons............................ Showers
a YP g ---------------------------• ------ ( ) — Cafeteria ( )
dOther fixtures -----•------------------- ------------•••• ---.•-•-•-••••-•-•----------------.._...--------•---------•---•-----•-......--•-•-•••••..........---
W Design Flow.............................................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 inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
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-.......................
Ri -----------------------------------------------------------------------------------------••---•--•••.........................................................O Description of Soil........................................................................................................................................................................
r
M ............... ........................o-•........._......_................._.._._._..............---................ _ ---' ....._...._...
U Nature of Repairs qr Alterations—Arms= when`applicable-_J ..._ . . _.....f _ _ ....
JnA�— --------- -------------•-•-----------------------------•--•-------•-----
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iIT1L 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.
igned - --- ------------
-
ApplicationApprov ••--• -----•-------------••••••----•---------......•-•--••----•--•-------•--••-••-•----•.
Date
Application Disapprove o e following reasons------------------------------•-----------------------..........................................................
................................ ...............•---....------•------•---------......------........__....--••--------..............................•.............................................
Date
PermitNo........................••---•---•----•----•-•----•--•-... Issued.......................................................
Date
----------- ........ - -
70V.1.-.'Jk Fes$ �......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...........................................O F............................._.........
Appliratiun for Disposal Works Tonstrnrtiun Frrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
r�/ ---------•---------------------•--••-----•......••••.
Location-�A��yyd�� rJ or Lot No.
. ... ....•. • ........ .......... ..... .............................•-••....-••--•..X••••••...........................................
Owner
W � Address
•.
Installer U Address
Size Type of Building Lot............................Sq. feet g ( )
�-, Dwelling—No. of Bedrooms.._:.:: •---.:• -----------•..._•--_..........Expansion Attic Garbage( ) e Grinder
aOther—Type Type of Building ............................ No. of persons....._...........•......__._ Showers
� ( ) — Cafeteria ( )
Other fixtures •---------------------
-----------------------------------------•---------------- ---------- ---------
Design Flow.....................................:._._•._gallons per person per day. Total daily flow.............................................gallons.
W Septic Tank—Liquid capacity'
apacity`..._......gallons Length........:....... Width................ Diameter................ Depth................
xDisposal Trench—No. .................... Width...:;............... Total Length..............._..._ Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter..............,:.... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank
Percolation Test Results Performed by . . .........................................•---•-••-•---•••••... Date.
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
(� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
..........................................
---.................................................................................................................
0 Description of Soil.........................................................................................................................................................................
x
U -••--•--•-•••-•-•-----•...•-•-•••---•••••••-•---•--••••--•----••--••---•-••-•-••••....-••-----•-•-•--•••••••••••-•••-•----•-•--•••--•••-•••-•-•-•-•---••••-•---•••----••••......---••--•-•--•-••••.....
U Nature. f Repairs r Alterations—An when applicable_. --••
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT1Z 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
� .../,v •f- � Date
Application Approved BrX,, --------------•-------.....-•----....----•---.......---•-•-•----•--••--•----•. •--•-------==-- •...
�" Date
Application Disa rove or a following reasons:.... ................
........................................------------------------------------- --------.-•---
Date
PermitNo......................................................... Issued-----•---•-----•--.---------••--••••-•----••--••••••--
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF..........
TrrtifirFate of �utli�anrp
T S PTO RTI ; That the Individual Sewage Disposal System constructed ( ) or Repaired
by-------------------------------.---- •- -.. .�-•--•--•-------------•------- . ....-------•-------........----------•----------......--......-----
- -
Installer l
at••••-•.;.40- -----;/-- .
has been installed in accordance with the provisions of T 5 of 1he State Sanitary Code as described in the
application for Disposal Works Construction Permit No.. '• -............. dated-----------.....................................
THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISF CTC?RY.
DATE............................................... , g (------ Inspector-•-------....!`:----�......................................................
THE COMMONWEALTH OF MASSACHUSETTS
11
BOARD OF HEALTH
Not ....../ .....OF........................ ...................... '"''!.
Tuntrudiun rrutit
Permission is hereby grant d.. ••... .....-------- E -••-----------------------•---•-------....-•---•--•---.........---....----...........---......
to Construct ( ) '-Rep ' an Indiv I Sew '" &sposal System
at No.-- .••••_ - --- ••... ........
as shown on the applicat' n for Disposal Works Construction Permit r-..__.. __.. Dated..........................................
---....---••---•-•---...._
�' -•--• Board of Health
DATE...•-•/ -•-�•---•--•-•-•--•-•--•---•-•-•...........•--••-
FORM 1255 A. M. SULKIN, INC., BOSTON