HomeMy WebLinkAbout0046 WEST STREET - Health 4A6 te-,Wrvi leles;tA5 tr:eet :'>
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s '138 006O
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i 25,957+/-S.F. �. a`a s. . 25,957+/-S.F. aaa
W �1 Septic System Notes:' Septic System Notes:
r,: ati 1
- 7 1.Existing I,000gaIlon septic tank to be r'+�I 1 Existing 1,000 gallon septic tank to be
` . •' replaced with new 1,500 gallon tank,. . , replaced with new 1,500 gallon tank, a.
-�..•' as shown. - as shown.
N7 .p 2.Existing leaching pi[to remain. y1— WorosED 2.Existing leaching pit to remain.
—.—— — —_-- \. 3.Original designcapacityjarthe, __— -{—---\ � l 3.Original design capacityjor the
F existing leaching
' � � existing leaching pi!is greater than � [i g pit is greater than
- 4411 gallons per day.- - m 440 gallons per day.
21' Exit
�••� ~•\ �H t ron
_ - - Prop.1,SOOGalln ,.. r/\ Prop.l,S00G 0tin
Sptic Tank \ - vl PIP Existing� —le Sepfic Tan6 ..
Existing. 16F
3 Ecdroont A9' - _ _ ___35' 3 Eedrnom
IA I�
f Dwelling
- ` Hse.#411 Hsc.i140
• T
GS
4>1
\
J
REVISION OATS BY -. • 1 - REVISION OATS BY -
•,A�\H Or M�!4 « i..,s �a -e'j, �,\H M
SITE PLAN.SHOWING �� �y SITE PLAN SHOWING ��� �y
vet NORMAN y
PROPOSED ADDITIONS ., Gp°ss""" pp�r� t PROPOSED ADDITIONS ` GRp6270,
No.12ra5 " , �.s — ��"/ No 12)05
J�'• ® CIVIL �o�'�.�0 CIVIL
Ffl Eh `� - '�l STV
® Wef151 ,rvO11.MN #46 WEST STREET �.S,aNA<�°\N�e ��we,sLO1Cry,,NA #46 WEST STREET sIONAI Eo\�
—� '! ✓ OSTERVILLE, NIA. 1. OSTERVILLE,\ MA.
or Al";r�r \\,, _ r �P�sH or At,r�n
APPLICANT: ENGINEER: APPLICANT: ENGINEER: �I� uAt�
OHMAN
Kathleen Capo,Tr. Norman Grossman,.PE,RLS " IH sMAN Kathleen Capo,Tr. Norman Grossman,PE,RLS5 R :i:IMAN
'`115 AGC Trust 93 Falmouth Heights 1115
AGC Trust 93 Falmouth Heights Road #4 " ghts Road,#4 "
.. `7�arclsnaEo t„r \
LOCUS MAP 20 Arnold Street Falmouth,MA 02540 °NAt L01 LOCUS MAP 20 Am Id Street Falmouth,MA 02540 vs t i1 D,-
SCALE: 1"=2000' Providence,RI02901 508-548-1920 Providence,RI02901 508-548-1920 * ;
SCALE: 1"=2000'
MAP SEC PAR LOT FLOOD ZONE ELEV. MAP SCALE DATE File: SHEET NO. PLAN NO. MAP SEC PAR LOT- FLOOD ZONE ELEV. MAP SCALE DATE Pile:'. SHEET NO. PLAN NO.
138 006 1 B -- 250001 11.D 1"=30' Feb.21,2005 Col W,\st 1 OF 1 C-903 138 008 1 - B — 250001 0018 D 1"=30' Feb.21,2005 Cdf Wes[ 1 OF 1 C-903
McKenzie, Marybeth
To: edlaceyjr@gmail.com
Subject: 46 West St.,,Osterville Permit No:TB-16-3756
Hello,
My name is Marybeth McKenzie and I am the health inspector reviewing your building permit of a garage addition for
the health sign off.At this time, I cannot sign off on the permit until I receive a site plan showing the new garage with
the setbacks regarding the septic system and floor plans of the addition. If you have any questions please feel free to.
contact me.
Regards,
Marybeth McKenzie R.S.
Town of Barnstable
Health Inspector
508-862-4644
1
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF•ENVIRONIIENTAL PROTECTION
FEB 2 3 2005
TOWN OF,BARNSTABLE`
TITLE 5 HEALTH DEPT.
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYStEM FORT
PART A
CERTIFICATION ' M.
- .
Property Address: fit;, tuo;7r ST.
Owner's Name: &jfhotjy i'Aeo
Owner's Address: S'+&y-
Date of Inspection: 2 zz o S ,s
Name of Inspector: (please print)M11TtNGw r_, ck, L -3
Company Name: SAME
Mailing Address: 3 A EA. So.
JIVMO,i�"a AMA Ca"
Telephone Number:Cte(8)9 69— l Lt'19
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 tiie inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP
approved system inspector pursuant to Section 15340 of Title.5(310 CMR 15.000). The system:
✓ Passes .
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: 'Z IZZ I OS-
lie system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
Notes and Comments .
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use. x.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM {'
PART A
CERTIFICATION (continued)
Property Address: "�b uJe51—5f
0%!- "U e wk A
Owner. At4�-koN J CEO
Date of Inspection: 2l z2 to<—
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
I have mot found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments: -
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired.The system,upon completion of the replacement or repair,as approved-by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements.If`not determined"_please
explain
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infihration or exfiltration or tank failure is imminent:System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the"Board of Health.
'A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break om or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are ieplaced
obstructions removed
distnbution box is leveled or replaced
ND explain:
The system required pumping more than 4 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
ND explain:
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: vveST 5 r -
0ST0Zv,'l i 4 M A
Owner: ! "-i wo Q yo ,
Date of Inspection: c)S' 3
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 public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15303(1)(b)that the ;
system is not functioning in a manner which will protect public health,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 any)determines:that the
system is functioning in a manner that protects the public health,safety and environment:
:.. _ The system has a septic tank and soil absorption s (SAS)and the SAS is within 100 feet of a
� yam
surface water supply or tributary to a surface water supply.
_ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. .
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well".Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria 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,provided that no other
failure criteria are triggered A copy of the analysis must be attached to this foam
3. Other:
J
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE O flSAL SYSTEM INSPECTION FORM
PART A
CERTMCATION(continued)
Property Address: q(o w2sf 5 T•
t)STCKuat%* M1/1
Owner: A*116bM. CApo
Date of Inspection: SO-Z?,(o�-
D. System Failure Criteria applicable to all systems:
You must indicate"Yes"or"no"to each of the following for all inspections: .
Yes No
Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
v. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than''/,day flow
✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
✓ Any portion of the SAS,cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
v Any portion of a cesspool or privy is within a Zone 1 of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_ ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water '
supply well with'no acceptable water quality analysis.]'This system passes if the well water.analysis,
performed at a DEP certified laboratory,for conform bacteria and volatile organic•compommds
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 S.ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.] '
Wei (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
� �N7
To be considered a large system the system must serve.a facility with a design now of 10,000 gpd to 15,000
gpd
You must indicate either`yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above
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 11 of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system has failed.The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CNM R
15.304.The system owner should contact the appropriate regional office of the Department.
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: '{b wC 5-f $}-
Ct` eTv hn J!
Owner: "cr is Q44- o
Date of Inspection: 2�zzlo��
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
✓ _ Pumping information was provided by the owner,occupant,or Board of Health
c�Were any of the system components pumped out in the previous two weeks?,
Has the system received normal flows in the previous two week period?
+� Have large volumes of water been introduced to the system recently or as part of this inspection?
Were as built plans of the system obtained and examined?(If they were not available note as N/A)
_ Was the facility or dwelling inspected for signs of sewage back up? '~
Was the site inspected for signs of break out?
Were all s stem component '.iN' ud
Y P b e SAS,located on site .
_ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
k/ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
_ Existing information.For example,a plan at the Board of Health.
✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)[310 CMR 15.302(3)(b)]
Q
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE:DISPOSAL SYSTEM INSPECTION FORM j
PART C
SYSTEM INFORMATION
Property Address: q10 we3 r s-r
-jyfe2v i I 1 C Mil
Owner• q-u{-L y Ckpc
Date of Inspection: z( 22(o S—
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): S Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
Number of current residents: 2-
Does residence have a garbage grinder(yes or no):two
Is laundry on a separate sewage system(yes or no):LLQ [if yes separate inspection required]
Laundry system inspected(yes or no):%jeS
Seasonal use:(yes or no): N)c�
Water meter readings,if available(last 2 years usage(gpd)):Zoo4 t 81 am 5'1 Z &-f D
Sump pump(yes or no):_tjo Zoo's Q o c,,o Lq 6 GP D
Last date of occupancy: cw-r�,J
COMMERCIAIJINDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): d
Basis of design flow(seats/persons/sgf,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no):_
Non-sanitarywaste discharged to the Title 5 stem a system(yes or no):
Water meter readings,if available:
Last date of occupancy/use: -
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: 6ftaA 461e S�pt-atE Tr2 wv��- c '(,1 a
Was system pumped as part of the inspection(yes or no):�Q
If yes,volume pumped:_gallons—How was quantity pumped determined?
Reason for pumping.
TYPE OF SYSTEM
t/Septic tank,distribution box,soil absorption system
_Single cesspool
Overflow cesspool
Privy
_Shared system(yes or no)(if yes,attach previous inspection records,if any)
_Innovative/Alternative technology.Attach a copy-of the current operation and maintenance contract(to be
obtained from system owner)
_Tight tank _Attach a copy of the DEP approval
_Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no):Lvo
r. Page 7 of 11 `
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address•• 46 WzS t
Q5 4ery t Ili MJ�
Owner: /krAkwgil cAtpn
Date of Inspection: 212 70 r '
BUILDING SEWER(locate on site plan)
Depth below grade: _ -
Materials of construction: cast iron i/40 PVC other(explain): '
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
.��1 T..) ('run[ wa�k-:N(r (`_.Ot�0��`nnl ,� �-•�M2 o�G C n�lpe�•�-t'a'n) .
SEPTIC TANK: ✓(locate on site plan)
Depth below grade: ,iS
Material of construction: /concrete_metal fiberglass polyethylene
other(explain)
If tank is metal list age:— Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)Dimensions: X r x s- cui•so,d.t, i
Sludge depth: 3'
Distance from top of sludge to bottom of outlet tee or baffle: 3,ro
Scum thickness: q -
Distance from top of scum to top of outlet tee or baffle:
i
Distance from bottom of scum to bottom of outlet tee or baffle:
How were dimensions determined: 51uA&R• 3aA9p
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels,
as related to outlet invert,evidence of leakage,etc.):
GREASE TRAP:01&locate on site plan)
Depth below grade:_
Material of construction:_concrete metal_fiberglass Polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.): `
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: LL6
Zvi t1e MIA
Owner:Aij",u4'Alob
Date of inspection: 7-127-jw -
TIGHT or HOLDING TANK: f�A (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass_polyethylene other(explairi):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in worldng order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: NIA- (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
PUMP CHAMBER (locate on site plan)
Pumps in worldng order(yes or no):
Alarms in worldng order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
Page 9 of 11
OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE-DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: N(. wf)1-S
oslefu e M&4
Owner.
Date of Inspection: •2 22 0
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type
bleaching pits,number
leaching chambers,number.
leaching galleries,number. `
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.): ,
G X$' prer-+•S�- P(A- w 31 .or S 6"e 4,of cA 2 .or w Ak f ie,,et CL4 I-"Wte or
CESSPOOLS: nlV*(cesspool must be pumped as part of inspectionxlocate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: (V�+(locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
a .
Page 10 of l I
OFFI CIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: L4.6 wesj-
oS iet-V l le
Owner. Atk",uy cApp
Date of Inspection: 21 zz I off'
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.
WrcST 9T.
To�un.i
WAfeg,
sv(.
Iff = 31
TA A
a A
loco cehl- tAtJK
pig 3 C4 STD,.
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
/ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
1 PART C
SYSTEM INFORMATION(continued)
Property Address: 46 wesT St-
nyZElCt,�ile
Owner. 41�c rj
Date of Inspection: 7 Zz( o�
SITE EXAM
Slope
Surface water wo
Check cellar✓
Shallow wells too
Estimated depth to ground water feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed: .
Observed site(abutting property/observation hole within 150 feet of SAS) ;
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain: -
You must describe how you established the high ground water elevation:
Top of r-&vn..4—o+j i s
1 7
q.s
f
if LT 11.4
N G w q 4-•e� '
fs
l
_ t`OCQT_1ON _ 5EW0,64E _PERMIT U'O.
-- V ILL ACaE. vle
5UILDF.R
- - DATE-PERWT-_155UED -'_
s
1
l+ Ole?
t3'
FRS... .....................
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® YIF HEALTH
_ a .6OF
Applirativit -for Dispaaii al Warks C omitrurtion Vrrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
---- ............I.- -• ..... _-•-•-----•-----...--•................•..........--•---
Location-Address _ or Lot No.
S._. _. k?_:----------- .�:'�_.�._) �.1?1............. ......-.t4a.0 ....
^►— lz
�� h 1_�'_l::
W Owner Address
Jrfvi2. IY1 ----•---------- -------------C ........ .....................
Installer Address
UType of Building Size Lot---'2. .�- - ....Sq. feet
Dwelling—No. of Bedrooms-_._-.-.--3--_-__.._----------------Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ---------------------------- No. of persons.--_-_-_-._._--__-----_----- Showers ( ) — Cafeteria ( )
Other fixtures ---- Q_= -'•--------------- -1-1 h�PC ��Li✓�•f+-�.
s
g -----------------gallons per person per day. Total daily flow--_--_-_.--._..-- -�.-.._-__-.-:--...gallons.
W Desi n Flow.....-_-__-_�____ y
WSeptic Tank—Liquid capacity-1OLIL .gallons Length__V.!—_G--Width.'-[-e'. Diameter---------------- Depth.5/'Y`:.-.
x Disposal Trench—No--------------------- Width....---------------- Total Len gth-------------------- Total leaching area--------------------sq. ft.
Seepage Pit No.........i----------- Diameter.....1_53........ Depth bel..w et....19............. Total leaching area..-�5k;�-----sq. It.
z Other Distribution box ( ) Dosing an ( ) ' " � ._ —
Percolation Test Results Performed b .` .
a Y - ... 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__---:_--.---_-------
cxQ'i' -----•---cd� ---- � �
q .. - ----
escripton of ----- --. d-D 4
- zy
--------------- - - - -- -
/
P- ---------------------------------------------------------------------------------------------------
U Nature of Repairs or Alterations V Answer when applicable..----------------------------------------------------------------------------------------------
------------------------------------------------------------`---•--•--------------•--------------------•---•----------------•----•--•-------........-...--••--•-------••-----------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI 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.
Signed-
�� -------------- ---------- -----QJ?412
-- Date
Application Approved By-I, -- - '�� = G'L�Z � -----------------------------------
Application
.a
Date
Disapproved for the following reasons: -------------------------------------------------------------------------•--•---.....-•--••...
---------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------
Date
Permit No. -------•-•---- Issued....
...................................................
Date
c r .s �'•'-......,;-<-*�'�<"°' TH
• COMMONWEALTH
, ALT FMASSA�U u TS
-,BOARD G H.
OF ._.... �. ---- ---------
;�
Application is hereby made for a Permit to'Construct or Repair ( ) an Individual Sewage Disposal
g y Sstem at
�
1 Location-Address ;t or Lot No.
- -a ° . 140__ .........V 5- ............
Owner �tg Address
Installer Address
Q Type of Building Size Lot.....'LA(k-w-Q_�---Sq. feet
U g— ""? ' Expansion Attic ( ) Garbage Grinder ( )Dwelling No. of Bedrooms_______________ ________________________ —
p`�, Other—Type of Building ____________________________ No. of persons___._--______________--__ Showers ( ) Cafeteria ( )
a _
d Other fixtures �=----._}- .--.w_:._...•.__.._._.`'_L.J-i 1{!�_s....__.G�r,!1d,4,�kA ............................................................
W Design Flow................. ........ ..........gallons per person per day. Total daily flow___________ ..................gallons.
WSeptic Tank—Liquid capacityLQ.o-ogallons Length_.S.r_4.h Width-4r'!_d-'!: Diameter___-_.--._._.__ Deptll.S'-_Y".
x Disposal Trench—No_____________________ Width.................... Total Length.................... Totalll aching area_-_..._-____---_____sq. ft.
Seepage Pit No---------t---------- Diameter_____ Depth be wl Tptal le,�chill <tre -----2:Cc...sq. ft.
z Other Distribution box ( ) Dosing.yan ,� �j 7
Percolation Test Results Performed by-`_:V------ - --- ------- .....4_F!'"" .
Percolation Date---------------------._-------------_
Test Pit No. I................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........................
D Description of oiEl_ �� . ---•---••......•----- ='------ --`-�------ � A----------
.+.... r ..
W(� �� - - -
______________ Y:_�._ � _____..... ._._________."�'--!-�-----------••----_-�.�-------_______-_________/�_._
V Nature of Repairs tr Alterations—Answer when applicable--------_`..........._..........................................................-___-_-____. --
Agreement:
The undersi�iled agrees to install the aforedescribed Iiidivid%ial Sewage Disposal System in accordance with
the provisions',of Article XI of'the State Sanitary Code— The undersigned further agrees not to place the system in
operation until'aertificate of Compliance has been issued by the board of health.
��. Date •---•---•--
Application Approved �3. - ._._...
e •----•-••---•-•--•-------------------•
Application Disy pprved for the following reasons____________ ___________ ____________________________ Date
Date
Y .,d
Permif,`0--------•-.----••--•••-----•---------------- ------ Issued. .. .� A:..
Date
'1 r-
4' THE COMMONWEALTH OF MASSACHUSETTS-
°� BOARD F HEA �;�
.�J'k...............oF........ ..... :..: ... -.-....-.-...-..........
.
. _ W.rrtifiratr of Tompl itrr
J TO•CERI , Th,4 the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by`- - ---- -- ---- --
/ f Instahr� ... .. ♦•—
at ". ct. L-••-•-----•---
has been installed'in accordance with -the provisions of le'XI of The State Sanitary Code as described in the.
application for Disposal Works Construction;-:Permit NUP__._._�_ �l............... dated._._,4'-a L:-7�t.._______-_-___
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT-BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION,,SATISF4401 Y
DAT>✓ _ .. "",... Inspector..,.,.,
o _
' { THE COMMONWEALTH OF MASSACHUSET.,TS
,.
BOAR OF HEA H
-. - ....-
77
No.- ................ FE
Id...............
. - Birip val urkq fit rt vvrt rrrwit
Perm> s +hereb grant ----------- f ......••.... -• --•---- •---...----- ----------
•..........
.........
16b r
to C u ( �,))"or p 'rr ,)_ n I c ' id Sew ;lIli posal Sy�em
at C 6u ar('r/
J/*
/..
Street
as shown on the qpplication.16 Disposal Works Construct- erm• o_ __ __________ Dated._ .//- _ �-
F�
-----------
_------------------------_
Bo d of th
DATE------=-----------------------------------------------•••-....-•-----••••••---
FORM 1255 HOBBS 4"'WARREN. INC.. PUBLISHERS r
THE FOLLOWING
IS/ARE THE BEST
IMAGES FROM POOR
QUALITY ORIGINALS)
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