HomeMy WebLinkAbout0152 WEST WIND CIRCLE - Health 152 West Wind Circle, Osterrville
A = j Z�, I -a
{
i
A
i
i
1
a
4 °
c
4
• FS
Comnionwealth'of Massachusetts
Executive Office of Enviromileiltal Affairs
Dept. of Environmental Protection One winter Street Boston Ma. 02108 .John Grad
' D.E.P. Title V Septic Inspector
P.O. Box 2119
Teaticket,MA 02536
wlu1AM F.wELo (508 564-6813
Governor
ARGEO PAUL CELLUCCI
Lt.Governor
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR
PART A
CERTIFICATION- ® , NOV
1s9?
Property Address: 1521A1est ind Circle Osterville - Address of Owner: wNOFggR AAy
Date of Inspection: 11/21/97 (If different) h�tTHDE jgB(f ?
Name of Inspector: John Graci Robert Graham
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 y
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 Inspection Is based on criteria defined In Title V
_ Conditionally P sse5 code 310CMR16.303.My findings are ofhow the system is
performing at the time of the inspection.My inspection does
_ Needs Fur a valuation By the Local Approving Authority not Imply any warranty or guarantee ofthe longevityofthe
Fails septic system and any of Its components useful life.
t
Inspector's Signature: Dater 11121197
The System Inspector shall submit a copy of this inspection report to the Approving Authority withinathirty,(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.
4
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
=: Coltipliance(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 of exhlbalion,of 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.
(rev1sea04127)97)
One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A L
CERTIFICATION (continued)''
Property Address: 152 Westwind Circle osterville ;
Owner: Robert Graham
Date of Inspection:11121197
_ Sewage backup or.hreakout or hioh.static water level observed.in.the distribution box is due to a broken, rt
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 K
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 asurface 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. n
— 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.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged
cesspool.
SAS is in hydraulic failure.
(revised 0427197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A ,
CERTIFICATION (continued)
Property Address: 152 Westwind Circle Osterville ;
Owner: Robert Graham
Date of Inspection:11121197
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.
(revlaed04i2r1971 _
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECLIST
y.
Property Address: 152 Westwind Circle Osterville Y
Owner: Robert Graham
Date of Inspection:11►21197
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.
_c_ — 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)1 2
(revised 04127)97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 152 Westwind Circle Osterville
Owner: Robert Graham
Date of Inspection:11/21/97
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 310 9•P•d./bedroom for S.A.S.
Number of bedrooms: 3
Number of current residents: 3
Garbage grinder(yes or no):-No—
Laundry connected to system(yes or no): Yes
Seasonal use(yes or no): No
Water meter readings,if availabl,:(last two(2)year usage(gpd):
n!a
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)
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: nra
Last date of occupancy: nra v '
OTHER:(Describe) nra a '
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System has not been pumped In the last year.Was last pumped two years ago.
System pumped as part of inspection: (yes or no)No
If yes,volume pumped:g gallons
Reason for pumping: nra
au.
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:
1987
Sewage odors detected when arriving at the site:(yes or no) No
'revised 04r17l971 ,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM;
-PART C
SYSTEM INFORMATION (continued)'
Property Address: 152 Westvrind Circle Osterville
Owner: Robert Graham „
Date of Inspection:11121197
SEPTIC TANK: x _
(locate on site plan) `
Depth below grade: 1s"
Material of construction:x concreate_metal_FRp_Polyethylene_other(explain)
If tank is metal, list age ova . Is age confirmed by Certificate of Compliance No (YeslNo)
Dimensions: Le'e••H5'r•w4'10
Sludge depth:t„ r,
Distance from top of sludge to bottom of outlet tee or baffle:26" w ,
Scum thickness:2"
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: 16"
How dimensions were determined: nra
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.)
Septle tank and all components are structurally sound.Recommend pumping system every two years for maintenance.
GREASE TRAP:_
(locate on site plan) "
Depth below grade: rda
Material of construction: concrete_metal_FRP_Polyethylene_other(explain)
Dimensions: rya
Scum thickness:nra
Distance from top of scum to top of outlet tee or baffle:rda
Distance from bottom of scum to bottom of outlet tee or baffle: rue , s
Date of last pumping;,l.
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.)
BUILDING SEWER:
(Locate on site plan)
Depth below grade: 2'
Material of construction:_cast iron x 40 PVC_other(explain) ,
Distance from private water supply well or suction line o
Diameter: 4—
Qmments: (conditions of joints,venting,evidence of leakage, etc.)
(revised WNW)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM.
PART C
SYSTEM INFORMATION (continued),
Property Address: 152 Westwind Circle Osterville
Owner: Robertcraham
Date of Inspection:11121197
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade: roa
Material of construction:_concrete_metal_FRP_Polyethylene_other(explain)
k '
Dimensions: roa
Capacity: nla gallons
Design flow: roa 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.)'.
roa
DISTRIBUTION BOX:
(locate on site plan) "
Depth of liquid level above outlet invert: roa
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box etc.)
roa
z
PUMP CHAMBER: +
(locate on site plan)
Pumps in working order.(yes or no)No
Alarms in working order(yes or no)Yea
Comments:
(note condition of pump chamber,condition of pumps and appurtenances,etc.)
We .
F 'f+
(revised 04127)87)
a
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 152 Westwind Circle Osterville
Owner: Robert Graham
Date of Inspection:11f21197
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:
rda
Type:
leaching pits,number: 2-6W leach pit
leaching chambers,number:ma
leaching galleries,number: rda
leaching trenches,number,length: rya '
leaching fields,number, dimensions:rya
overflow cesspool,number:nfe
Alternate system: nfa Name of Technology:_we -
Comments:(note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
The leach pits are structuratiy sound and functioning properly.One pit had 1'In It,and the other was full.
CESSPOOLS:_ -
(locate on site plan) -
Number and configuration: rya
Depth-top of liquid to inlet invert: nla
Depth of solids layer: rda
Depth of scum layer: nra
Dimensions of cesspool: We
Materials of construction: his.
Indication of groundwater: rda
inflow(cesspool must be pumped as part of inspection)
rJa '
Comments:(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
rVa -
PRIVY
(locate on site plan)
Materials of construction: rda Dimensions: �g .
Depth of solids: his
Comments: (note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
PdvyComments
(revised 007197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ,
PART C
SYSTEM INFORMATION(continued) z'
152 WestMnd Circle Osterville
Robert Graham
11121197
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)
De
a A News
G
AA
71- . gC � y
(revlaod04f17A7) Tape ! of 10' ,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM
PART C
P SYSTEM INFORMATION(continued)
152 Westwlnd Circle Osterviile
Robert Graham ++
11121197
r
Depth of groundwater 12+
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from design plans on record.
Observation of Site(Abutting property, observation hole,.basement sump etc.)
Determine it from local conditions
Check with local board of Health
Check FEMA Maps'
Check pumping records
Check local excavators, installers'
Use USGS Data
Describe in your own words how you established the High Groundwater Elevation.(MUST be completed)
USGS Maps and Charts
(reviaed04R7197) ,. '�00 10,Of 10 :
TOWN OF BARNSTABLE
SEWAGE #
V1Y.LAGE ASSESSOR'S MAP LOT ljjIIq
INSTALLER'S NAME & PHONE NO. A & B CANCO 775-6264
SEPTIC TANK CAPACITY 1"d
LEACHING FACILITY:(type),--',�z�a / 5' (sue)
NO. OF BEDROOMS_ �_PRIVATE WELL OR PUBLIC WATER
I
BUILDER OR OWNER
DATE PERMIT ISSUED: / _ 9 - r
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No /'`
4P
1
fi
Board of, HeslZh
7 c-,.-M Barns table,
Cl.� Sw(534
No.m..... �IyjinnisF ' Nrlassachuv'tts 026601 Yv3 .............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...........7r ..................OF....arn*".[a.
.........................................................................
Appliration for Disposal Works Tonstrurtion Vrrmit
Application is hereby made for a Permit to Construct or Repair (*) an Individual Sewage Disposal
System at:
........................ ..................................................................................................
Location-Address 6, r•
Lot N
......... ............... ....... .............................
-%.......................... .................
Owner Address
............................................................ --- 6o M .....................k"Lyarm......................
Installer Address
Type of Building Size Lot----------------------------Sq. feet
U
Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder ( )
Other—Type of Building ............................ No. of persons............................ Showers Cafeteria ( )
Otherfixtures -----------------------------------------------------------_--------------------------------------------------------------------------------------
Design Flow.....................................I.......gallons per person per day. Total daily flow............................................gallons.
04 Septic Tank—Liquid capacity............gallons Length................ Width..__...._._..... Diameter.___.........__. Depth_...............
Disposal Trench—No..................... Width.................... Total Length.._..__............. Total leaching area--------------------sq. f t.
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_-_-_.-.-_-_-__-..._---.
(Z Test Pit No. 2................minutes per inch Depth of Test Pit._.___......_....... Depth to ground water_.__._..........__.___..
Ix .............................................................................................................................................................
0 Description of Soil....................................................................................................................................................................
U .........................................................................................................................................................................................................
............................................................................................_....................U........................................ ....... ....................
Answer when applicable.7!?11.........).00_0._�kj..lec", CAS...____.
U Nature of �Repairs or Alterations
.P JAj_W.....................................................................................................................................................................................
j gelrement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of T IL TI 1E 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.
(Zy', Signed...... ................................... --- ... ...
Application Approved By.._.. ------- ............. ........ Date---- -------
Application Disapproved for the following reasons:--- ............................................................................................................
........................................................................................................................................................................................................
Permit No..9 ............................. Issued_--;3. Date
........ .......................................................
Date
THE FOLLOWING
IS/ARE THE BEST
IMAGES FROM POOR
QUALITY ORIGINALS)
i -A=
m /
DATA
No. � Fxs ......:.............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
. .----.---• .OF.._�.:` :�... ... -.......`..................... � .........-----------------.....----•----•----------.------
Applirta#iun for Bi ipao al Wurkii Cnunotrur#iun anti#
Application is hereby made for a Permit to Construct ( ) or Repair ( ` ) an Individual Sewage Disposal
System at: 4
...................................................
. . .��e
Location-Address or Lot No
, �' i4r✓ lie
Owner i Address
(� f` 1 ( r. > I. ,e., (, - f• f't ..a't.,
---•-•--•--•-------•................................•--•----...•...._........_._.................. ........................................--------------•--^-----•••-......-•'-......-_........._._
Installer Address
d Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms................................ .....Expansion Attic ( ) Garbage Grinder ( )
P`4 Other—Type of Building ________.___•-_.-_.-__-_-_- No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures _________________________________ _
d --•---------------••---••-•••••---•--------------------
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 ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water-._._--._____-_________-
Gi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water---------------------
....................................................................................................--•-•---••••••--•-----------•----••••--•--•-•-••-••--•-----•--•.....•-••-•-•--------•-••.._.....••--.........................................................
0 Description of Soil........................................................................................................................................................................
W -----••-----• ----------------------------••-••••-----------------•-•-•-•--..._.._..-•--•-•--------•--... -----•-•----....--•-----••-••••-•-•-----•-•------•----------•••-•---_:-••--••-----•....--••-
UNature of,Repairs or Alterations—Answer when applicable._.......:_°:a._._.G.......i-------�--�_-1---r -;� -_..--_--- -1 its
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
i:I T r'1 X
the provisions of 'T .,,,. 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.
Signed.....'/ 1,............................
Application Approved By...- ---••-•---•-•-•------•---_-• •-•... ...� � a --•-----------
Date
Application Disapproved for the following reasons:...............................................................................................................
------•---•---••----•-------------------------•.-----••--•--........... •---......-•••......-----•-•--•-•••••• -------•--------------------------•-••-----•---•---••...•.....
----- -----
-� Date
PermitNo....._.. ............................................. Issued-----------•----•-----------------------•---------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF... .................................................................
01. r f iratr of Tuntpli atta
Tr-. /� ' T TIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( }
_ / I ' .......
at........11�k..w-�..��.... C.LI. � -InP.` ............ . �r!!•.�`
has been installed in accordance with the provisions of T e_ tate Sanitary o . a d scribed in the
application for Disposal Works Construction Permit No.� �.�?.f
...... dated_. , ..fig-______________
THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUE® AS A GUARA TEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.................r.4l L Q4-----7"./.L_s ....•.. Inspector................------.•-•2................................................
`` THE COMMONWEALTH OF MASSACHUSETTS
l�lf kr'.
BOARD OF.. .HEALTH
..
NO......................... FEE..:..6.................
Map tiff #ritr iun rrnti#
Permission is hereby granted----•--•......•-•................................••-••--••----------•-----•-•--.... .....................................................
to Construct a� orC� s� , anj ivi a) (�ispos6� 1 el IJ/
atNo...----•--••-••--••••-•-----•-------••--••.•••--• ----- ;� •---•------•---
Street ��
as shown on the appli tion for Disposal Works Constructio mit N�............. ted_� ---------_-___------ ...........
r�
DATE--------------------------- ----•---•--•-----•.......................... Board of He.lth
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
-LQCATION 15 SEWAr,GE PERMIT NO.
L_o wp /,ai�J C t �� 7
VILLAGE
evuf e 1 `� f d
INSTA LLE-R'S 1 WIN E A ADDRESS
J e'r6 oo ►1N�1
R U I L D E R OR OWNER
DATE PERMIT ISSUED
r -4ivI14 1YAJ-7
I�
DAT E COMPLIANCE ISSUED
6J-
{
Loi a�
41
Y
d�
yy !�
No..�/.._ ..Z L_ - Fzs:....... ............
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
ApplirFativaa for 14upuuFal Workii Toustrurtiurt ranfit
Application is hereby made for a Permit to Construct (_(_j or Repair ( ) an Individual Sewage Disposal
System at:
........4A1 �....a �., .... R. ..�r,t _ ........... --�. OR.i9-`IL C
Location-Address o
- .1 ®.... }'.. ...... .. 4.... _ `.... ... .a.....rk...........
a(� y�
a Pam!.�_Q....... .. f !.n. � . -•---•.............. ... res- - I ._ ....
Installer Address
Type of Building Size Lot._ Sq. feet
Dwelling—No. of Bedrooms..............�-.__:..._....____.---._._Expansion Attic ( ) Garbage Grinder ( )
p, Other—Type of Building J)W__ No. of persons..........(a............. Showers Cafeteria ( )
a' Other fix r 'V
-------------------- - -
WDesign Flow............... .... ...................gallons per person of drapy. Total dail Aow.......... .l:.l_.__.._______.._gallons.,,,
WSeptic Tank—Liquid capacity/AK.allons Length...�Va_.6-___ Width.....?-•--_ Diameter________________ Depth_.�..,�..
x Disposal Trench—No. ........ ..__. Width......./........... Total Length.........._...----- Total leaching area.......... .......sq. ft.
ay
Seepage Pit No.--_____I_..._.._... Diameter--------6-------- Depth below inlet..... ........... Total leaching area_ . _ _ r.sq. ft.
Z Other Distribution box (-t) Dosing tank p
Percolation Test Results Performed by._.--� �.W0-4 ... 6_ .6.7EfJY.x6 Date.....-.'�.F.._ .
Test Pit No. 1................minutes per inch Depth of Test Pit-__-___--_---___--• Depth to ground water- /-0-Wb1'rC9
Gi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
9 •-------------- ...... j �j...
O Description of Soil..........................� _I.V., /Y - -- -- - -
x
W ---------------------------------------------------------------------------------------••----•--•------•-•--------------------•-------•--••-•-----•---------------------•......---••--•---•-----------
VNature of Repairs or Alterations—Answer when applicable..........................................................................................:....
---•---•-------------------•----------------------•----••-•------------------------..............-•---------------------------------------------------•----------•---------------------.._..-----------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITIS 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been .ssued by the bo rd health.
ApplicationApproved ------ -•--- -------------••---------------------------------------••---- ,/ /--- -------- - ----------
Date
Application Disapproved f o the flowing reasons:-------••---•-----•-----•-••••---------•--------------------------• ......................................
.................................................. --........-----•--•-------------------...------------.......-•-....-•-----••---............----•-........ ..........................................
Date
PermitNo--------------------------------------------------------- Issued......................................................
Date
No.. ...........................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEA' T"7' 1 1 1
-- ---------------
Appliration for Dispotial Works Towitrurtion an it
Application is hereby made for a Permit to Construct O or Repair an Individual Sewage Disposal
System at 1, 0 ,C_71
.........
. ...........
I..............
Location- YA Address N 0.. _0...:7�hl....... .......122. ...... in.,... ......................
-W d ..............
...........
Installer Address
Type of Building Size Lod S�,L.PT.Sq. feet
4 Dwelling—No. of Bedrooms............ ..........................Expansion Attic Garbage Grinder
Other—Type of Building No. of persons.........6-------------- Showers Cafeteria
04 Other fix r
_:::::::::.:gaiions per person pqr 44y. Total dall. (flow____.._... -U..................zallons.,
Design Flow______________ 3
1:4 Septic Tank—Liquid'capacitytA-M. .gallons Length.10.4.... Width__.. ......... Diameter________________ Depth.-&sly_
Disposal Trench—No. .................... Width....../............ Total Length.__....._...._....._ Total leaching area sq. ft.
Seepage Pit No------- -
j----------- Diameter........14 Depth below inlet....- .....
V......... ow 6------------ Total leaching area_i�(12....7..sq. f t.
Z Other Distribution box Dosing tank CP11
Percolation Test Results Performed by , , kd.!e`� Date.....''Z.
Test Pit No. 1................minutes per inch Depth of Test Pit...._......__....... Depth to ground water- ap_f fz#-r6-R
IX4 Test Pit No.1�2................minutes per inch Depth of Test Pit._............._.... Depth to ground wate:/1.....................
............. )...y. . ......................................................................
.. ... . ... . ------In
0 Description of Soil......................... ...... ..........................................................................
---------------------*------------ ------------------------------ ----------*--------------------------------------------------------*-----------------------------------------------
------------------------------------------------------------------------.....................................................:-------------------------------------------------------------*-----------
U Nature of Repairs or Alterations—Answer when applicable..............-------............................................................................
......................I.................................................................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been .ssued by the boArdcif health
e L
Z,
Application Approved
............... ...•.. .....L/.................
Date
Application Disapproved t9e,th!llf lowing reasons:.............................................................................................................
.................................................Z....................................................................................................................................................
Date
PermitNo.................................................------- IssuedL.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALT�
....... n........OF... .........
(Intifirate of Tompliaurr
Ll
THIS IS TO CERaIFY, That the Indivi uaL S'w 11 Di osal System constructed
-4 or Repaired
by--------............................. ... ...... ...... ........................ ------------------Z.........---------Z -------
tall
at.... .... t ........ .........;.................has been installed in accordance with the provisions of TITLE 5.qf The State Sanitary Code,,ds des'cribed in the
application for Disposal Works Construction Permit ... . ..... e�
.. ...... .......... dated--. K. .................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. 79-1
DATE............. ............... ....... Inspector.............. ...................................................
THE COMMONWEALTH OF MASSAC SETTS
BOARD OF HEALTH
(e i2........... ...OF.......
No.......................... FEE.......................
13ispollfa Porkii Tons
Ir ion eranit
Permission is hereby granted.................................. ....................
...................
to Construct orNRepair Individual Sewage Disposal,,
7 ,System
atNo 4"6. ......... . . .............. .... . ..e_.1 4e..................
Street
as shown on/the/ap/ica 'on for Disposal Works Construction Permit No_________________ Dfited..........................................
.................................. .............................................................
Board of Health
DATE Y •
... ... ...... .......
71 . .....................................................
FORM 1255 A. M. SULKIN, INC., BOSTON
E Lgv.= L,f ,i _AJ_L. 1`L Eel'. '5 1-"uj iJ Ae W t r Aa S E a, L_r v�L
CI J L L7, C=AT L�t�'l PLJ�►��
t PtTCI� ALL Ltt4ES A MI�.ItrnU�i or- I1L'> IFC'c'?
h i UntLE-1-, OTNE+- -)tSIE 5P17_Ca+F1ED.
— A►_,L P%PV.S -tO A"Q tot TNTc sYST>;M St�At1-
C / �
,TA"
� ; r �C cs+.sT 1�t..1 catZ 5c..��n v>� 40 p�J c
AL- 24 '1 0 ,� ! V ((1 L `3EPTAie1C$ IDt-,T tZ113JTt�.J $fix A li)
EN
_ _ -._.-__ l� �2EN4)✓E Au U.1S.J TA3�E Mte HE�lAst AL( ERuNDER PAVING
i _ "C ikl�JEQT El EVATIC>.SS OF LEACHt �YfTS F�
� � �� COI � � � ...►�,
J_ _ . �. r^ t � 1 A eAl7t US OF /'v A4jo
_ 1 \' / _� - WIT �^ 1 at
G ---—� O �� , - --r"c P A k M�_TA ry�t- ex�z D o I- I,4 .LTA, ►•.�usT
�^ \'-"� �� �� r>E NC5_rIIr1E-D WHE�1 Tµc �y`TEM t5 NEAi�
Al, "� i � � ` �' C�-�M�'t--ETtc�..J .o.�O F�2to�•' To °,.ae*C�F'iu._tu6,
- I J ! O Q V � 11J ® V �� — l��l E5� OTN�2 ISE �soTEC� Au_ v, 5 �►�
N- �` �Cot�6PU�.f�tbTS S►�nu� p.�E ��tSTA.��ct� two
tt
�� f �... TEt� z'�i � i O G O C (O ' D Q ACCC32pa«Jc_is 4�/tT> t T IT LE _.� c F 'TZ�� •�TL,TE
TYPICAL _Dt5TtL16_uTtB�1 �jC9}C I ff
t t O CO O �� 'V l�' ®
LO - 4 WN1Ct� loalcvy Apti�Ly.
►iL» To §GALE
�, T�/� 4 % U GA-L. �F F"t'
t7B�E,@ VAT/ Nor�o sc..L E
-
.. 1�YC:rY'E.: TI..►.yKS r2iatt.O�F:D ?i•iC'Ou4Npv'T' � � -•«w..•:«.e_____. - ,.. _._.
�FefOLAT/O�/ TLC = 11Vi17 jir7Gil _ e
,. 2A it1D�:>`> � SCGT C 7I• JM htd A
OB"E,eV/!7►/oi115 Qj/: o +sE ev t.T
^ r,o-fTcor••t. Ct'�-JC is •4000 roa__ TpS i 1+tnK}{ rs uP Yo
,OoA,eo aw- l�.4LTN -- -- _ ae��w � �styN �txs tee►
ENG/NEER' "Fa+, Fc>u+ApA-nc> '
PA7WF tY.l.tSµ +�tl►,Dr► F mjrt.t•t GQ_I iL E i�114Lt C�IZ�► /) tL7C.
�Fax1iSN CzFPLE - tS4 Ta►KKr4F¢c} a°.E¢`d+ 4 $ IEACN�►JG
1' f
�AGle
F°LL �s �•t p p
K VY t—S T YV f / W D C '�C CY
!')tQ *. M
4I k 6 A
d 3igc, - m -
•t INV� :.jct�: Q .
eetyFoccry cn.►ft- [3lST FAX. {7 ®P ', •
ram, r 3 s' Q} O C7 V t 0,&T,►t•,,8 Orr
I 4 ' Y TYP I CA t ._n----
' t.►nT Tr ��.L+E: LE GN1tJla
CT N P.4RCE/, LOT APPRE&S
MAP SE lO
�C)T _
j 4
1 -
i p
rt:
7
4.
y ,
.. +�- jj � • .. •, Al
PROPOSEP PNE.L�C ING ,COCA TION
t?E6/GN cell-eels ::�'— i',i00R'3:fe� C.avTdGtC -N 3f St ,
PROPOSER SEWAGE D/SPOSAI. SYSTEM
A/v.M B Eye
es �itGO• �/"dj�L- / FtG6ER1 �n
z 5` �,.�/,�,� �` �',l,',�/�.�' .a,,.�.�•.��``�•.-c�-..
f°ze iftC 3oN -045e!ate f Acoc fTJrs,✓ t
G�ILLGGVS - o RAYC,30ND
,�E4u�� oes�,c. �rnt • Prr. ,�r�a.21583 , r` ;f �. ���- � �.,
G�AC�/rtt6 /
Z6,rG 14!/.t/G -
t f \ Pi?OP05ED LMAGHIN� PIT '? 6.pr54..;Gp.t�CT: luY6..1aJwL'
�- �,
° 1 °EGINtWG tPqC.
0 5p05b%
100% E x p o r`1 s 10 nt .. 93' ` h ( F1�.L. C�t7TN 14 1 �►
°
f.6�Y1
S1c.Jfa t75�Gt ,..4 a+a} ROB
.7' f�r , FAR
AS NU TElJ OF
h
.v
13
C05
!sY G li 1k�' IC y
5� 4i�t�. AP;AL1(: •�� • V O/ a-3- - r :..J _ i ."�m. # ;$., ,..:...:� -fit•Y''?-r•c--P +3&. et _ .. ,rw
,G Ems• !%�i�...