Loading...
HomeMy WebLinkAbout0167 BLACKTHORN ROAD - Health 167 Blackthorn Marstons Mills A = 046 027 Commonwealth of Massachusetts Title 5 Official Inspection Form z; Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Ga '� L_T *-_??LA00HVVA.J Prq�e�A�ddress et V)�'_ }� 6k 1 Owner Own s NameNaC ,/�r' �V ��1 information is ��1 required for every page. City own State Zip Code Date f Insp on Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:fling out n A. Inspector Information 51 # 13(0 28 fillip out forms on the computer, :D V I C) •� • � %; I use only the tab � V�•� key to move your (Name of inspector cursor-do not use the return key. Company Na •�mpany Address Cttylfown� Statel Zip Code Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above;the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintena ce of on-site sewage disposal systems.After conducting this inspection I have determined that the s m: 1. Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails .5 nspec s Sig Date The 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 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. l5insp.doc•rev.7262018 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments VVII - Property Address Owner Ovmer's Name CW information is t�v� w� 1���it , 1 A ��/ Z ze � / required for every 6`� t,�1C �`' 1�.�--?� �-�t7 J page. Cityrro�n State Zip Code Date of Ins on C. Inspection Summary Inspection Summary: Complete 1,2, 3, or 5 and all of 4 and 6. 1) Syste asses: I have not 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: 2) 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. Check the boy:for"yes", "no"or"not determined" (Y, N, ND)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 infiltration 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. ❑ Y ❑ N ❑ ND(Explain below): t5insp.doc•rev.7/262018 Title 5 Ofidal Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address . Owners Name information is ����` i� V1 l` t /_ � 2 �� required for every 11 1�' ' i/l.3'"� page. City/Town S to Zip Code Date f Inspecti n C. Inspection Summary (cunt.) 2) System Conditionally Passes(cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out 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 replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ 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 ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 3) 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. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/262018 Tide 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner dine s Name information is il/I�C.�Tt1,, i L_ D20- q required for every , ,1 ✓rV"y✓ V" 1l•CTJ V Zg �l page. CitylTown Yte— Zip Code Date o Inspectiori C. Inspection Summary (cont.) ❑ 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 b. 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 system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and 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 fecal coliform bacteria indicates absent 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 form. c. Other: 4) 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 l5insp.doc•rev.7262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface SewageDisposal System Form-Not for Voluntary Assessments Property Address 6 Owner Owners Name information is required for every O zi,,q _ page. Cityrrown State Zip Code Date o*Ins C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Iquid depth in cesspool is less than 6"below invert or available volume is less han%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. ❑ Any portion of a cesspool or privy is within a Zone 1 of a public water supply 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 fecal coliform bacteria indicates absent 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 and chain of custody must be attached to this form.] ❑ r, The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ 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. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section CA. 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 t5insp.doc•rev.7262018 Title 5 Official Inspeclion Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner Owners Name information is O� Q ,L� 70` required for every �`p_ � yl W C/ C� page. C"Town to Zip Code Date of spection C. Inspection Summary (cunt.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed.The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or"no"for each of the following for all inspections: Yes No �❑ Pumping information was provided by the owner,occupant,or Board of Health ❑ 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? IJ—Q/ ❑ 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? p g t R/ ❑ Were all system components, excluding the SAS, located on site? 631 ❑ 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? ❑ 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: ❑ 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(5)] l5insp.doc-rev.7262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts u Title 5 Official Inspection Dorm Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner Qviner's Name ,�A information is (Y11A_/)�25P , i 2 SA/�►1 j 4_ 1�- Q Z Z 119 required for every 'IF�Yi 1 VDU Y v(�W;/ tY,rr` �j Z(� page. City/Town State Zip Code Date of speebon D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Description: Number of current residents: Does residence have a garbage grinder? Cb45Tv�LWWCI P ❑ Yes No Does residence have a water treatment unit? ❑ Yes o If yes, discharges to: Is laundry on a separate sewage system?(Include laundry system inspection information in this report.) ❑ Yes No Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes No Last date of occupancy: 90P LAIM Date t5insp.doc•rev.7262018 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal system!Page 7 of 18 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner Owner' Name information is Ukerequired for everypage. City/Town Zip Code Date of I spection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? Yes ❑ No If yes, volume pumped: ns ' How was quantity pumped determined? � fI Reason for pumping: t5insp.doc•rev.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner Owners Name information is LA �2&4 6 od2 z� ��\ required for every page. City own fate Zip C Date Ins on D. System Information (cont.) 4. Type of Sy m: 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)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components,date installed(if known)and source of information: ,PiT 16m , N 010200Q_1�? Zco-Z, Were sewage odors detected when arriving at the site? ❑ Yes U, No 5. Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron �40PVC ❑other(explain): Distance from private water supply well or suction line: ID/4— feet Comments(on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7262018 Title 5 Official Inspection Form Subsurface Sewage Disposal System Page 9 of 18 Commonweafth of Massachusetts 'UW)" Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address - 1 Owner Own rs Name information is C L., M I � ISta c>required for every ✓ / ✓ r►page. CitylTown Zip Code Date of I pection D. System Information (cont.) 6. Septic Tank(locate on site plan): it Depth below grade: feet Material construction: concrete ❑ metal ❑fiberglass ❑polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of ce ficate) El Yes ❑ No Dimensions: Sludge depth: r� Distance from top of sludge to bottom of outlet tee or baffle �l Scum thickness (10 y r, Distance from top of scum to top of outlet tee or baffle t I Distance from bottom of scum to bottom of outlet tee or baffle v How were dimensions determined? �f Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): ry ItAlpiqq t5insp.doc•rev.7262018 Title 5 Aflicial-Inspection Forth:Subsurface Sewage Disposal System.Page-10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection form Subsurface Sewage Disposal System Foorr(m-Not for Voluntary Assessments Property Address �vti O��l Owner Ow'nerr''ss Name information is required for every ` page. City/Town We Zip Code Date]ofEspiecU D. System Information (cunt.) 7. Grease Trap(locate on site plan): Depth below grade: feet 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 p❑mping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 official Inspection Foam Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y' 10-7 '&� lk4 P,4'D Property Address Owner Owwr's Name information is r 1/l,nf) L, j, ` ' �/�I 1 ' © fZ required for every l'7 �✓1 V v1, U: page. Citylfown S to Zip Code-ASDate of Is, pection D. System Information (cunt.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches,etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert Z' 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.): LAD vw1 Wit) �'r L�4 EAU l pC-AI7.Ok,�,-1 iA�7 I CIC-1A G.?tt4 4t, t5insp.doc•rev.7262018 Tide 5 Official Inspection Form:Subsurface Sewa ge age Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments s I(�� L��� � Property Address Owner Owner's Name id is reequirequire for or every ' •t r`Ty"' "'�`t ✓ 1 page. City/Town State Zip Code Date of nspectio IF D. System Information (cunt.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located,explain why: Type: leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number: innovative/alternative system I Type/name of technology: t5insp.doc•rev.7R612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property dress Owner rs� ' �7 information is every 1«, 0 .2 , u- r v I y'l d [1 z j required for eve .c1 �— page. City/Town State Zip a Date o Inspectio D. System Information (cunt.) 11. Soil Absorption System(SAS)(cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation,eic.): 12. Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions cf cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): t5insp.doc"rev.7262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner is Nameinforrnation is ,/q required for every 404UMllD v- LL1c/ page. CrtY�To S to Zip Code Date Inspecticin D. System Information (cunt.) 13. Privy(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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Dorm Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 16-7 AW-4(�A 6� Property Address Owner Ovyner's Name information is y��n�o J ✓2 required for every ' `�`�' page. City/Town State Zip Code Date of spection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below: ❑ and-sketch in the area below drawing attached separately t5insp.doc•rev.7262018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts 4. 9r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �. ��G�� '1r 1� � �Property Address OwnerOwner's Name information is � ,1 required for every �' "(j`-L kt" 2 M 4—`� 5 e--- A D :21 Z �, page. City/mown S e Zip Code Date o Inspectiorl D. System Information (cunt.) 15. Site m: C ck Slope Su ace water Check cellar ❑ Shallow wells Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If-hecked,date of design plan reviewed: Date Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Bo rd of Health -explain: ('Dj1-UWL- MAP 'Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: 4 UTILA?Iff'� it 1�1712 Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments PropertAAddress Owner e,r As Name 4ofspection information is aAILG,�q�1 ��,� f Cv required for every �l'' ✓�`� page. City own State Zip Cod Date E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: 2�BCertification: spectcr Information: Complete all fields in this section. Signed&Dated and 1, 2, 3, or 4 checked M C. Inspection Summary: 1,2, 3, or 5 completed as appropriate 4(F ilure Criteria)and 6(Checklist)completed D. S stem Information: Y For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-•rev.7262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 Assessing As-Built Cards Page 1 of 2 TOWN OF B LE LOCATION SEWAGE 9 _01 l yp I,A ii ASSESSOR'S MAP&LOT.b46 0,0 INSTALLER'S NAME&PHONE NO.ID)1I i IA SEPTIC TANK CAPACITY i S00 ITN I f t LEACHING FACILrrY:(type) II�CGI 'fQiATG�S )(size) -&A Oi NO.OF BEDROOMS 3 t ' 4D two 6k,-V tt BUILDER OR OWNER PERMITDA-E: `"�Z—�Z COMPLIANCE DATE: I Separation Distance Between the: i 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 Feet within 300 feet of leaching facility) Furnished by %Iz11, > cool s•� � z i l was a xott � O 1 )VI-L"Y.I 4 !-Z5 J 49 https://www.townofbamstable.us/Deparkments/Assessing/Property_values/HMdisplay.asp?... 3/8/2019 No. v"' ! Fee /✓�/ s g THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: r.: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Rppfication for Misposal 6pstent Construction Permit pplication for a Permit to Construct( ) Repair(4 Upgrade( ) Abandon( ) ElComplete System dividual Components °Location Address or Lot No. �/A_ 4, %A N� R p Owner's Name,Address,and Tel.No. o B s�pt� Assessor's Map/Parcel ('7 j44P�-fY61746N"�—Z>� 1119 II10.0 '0rn Installer's Name,Address,and Tel.No.B ij,.B EACw)v.A l O& Designer's Name,Address,and Tel.No. I y -Tco_Scrrj Ltj Forc54-L<L1c y )7• DG 53 Type of Building: Q Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) Al gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) _D OX. O Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Si ed Date Application Approved by - Date Application Disapproved by 1 Date for the following reasons Permit No. 2a s Date Issued �� �I t No. • ! Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ftplication for MispoBal *pstem Construction Permit �.A ��pplication for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) ❑Complete System � ividual Components ,r. Location Address or Lot No. Q A� Owner's Name,Address,and Tel.No. JCHh G 7 _D AL, 1 L`1 (31 ae>rC-t�o r� R� i9ssessor's Map/Parcel V 1 1 5 Installer's Name,Address,and Te-. o..B _B EPIC.,J.. �O.,\ Designer's Name,Address,and Tel.No. I� "Tc�Jcrrc t L►J FoccSi4o_1c. y'17 OG5.3 Type of Building: p 1 Dwelling No.of Bedreoms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) A/ gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) g n g n Date last inspected: Agreement: The undersigned agrees tc ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of T_tle 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date Z -2-: 9 Application Approved by Date 2— 7 � Application Disapproved by Date for the following reasons Permit No. ,,c C q-( — U 7!— Date Issued _ --------------------------------------------------------------------------------------------------------------------------------------- * 1 Q THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( �' Upgraded( ) Abandoned( )by S. e A at (�� �,2 r,� {,� { has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.A2�_dated L Installer {��X fir,, )C A; A //�� Designer /T#bedrooms /� J Approved design flow %may/�Q- gpd The issuance of this p a it shall not be construed as a guarantee that the system will{ nctio ;as designed r Date l G1 Inspector e g ---------------------------- .-----------;'-------------- _ --------------------------------------------------.---------------- No. Oil --�� �^ Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal *pstem Construction 'ermit Permission is hereby granted to Construct( ) Repair(,.e) Upgrade( ) Abandon( ) System located at���T �� 1- _ 12C) and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. '" Date /� _ �� Approved by 0 TOWN OF BARN LE ,1, LOCATION SEWAGE # VO 'O l 1 VILLAGE k i I M I ASSESSOR'S MAP & LOT �2-7 INSTALLER'S NAME&PHONE NO.1( -kRN\ `l'7 l 0 1 SEPTIC TANK CAPACITY 1 SOO MQXABUTN 1< O LEACHING FACILITY: (type) IKVPUYEATCKK ( y')(size) 'A OVWt 3n NO.OF BEDROOMS OLD 100C) BUILDER OR OWNER Sk.W PERMITDATE: COMPLIANCE DATE: t — lcol 'oz 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) Feet Furnished by �t CRI— I3.5' 3a 6 � " A �' a z— pt8/ 0 � nr��,l i r 52•ls �- `CW y I�VV�i� 2 � 1 r,.S 1©00 o , A pit i No. �.UO a Fee THE COMMO WEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Tippiication for Migogal *pgtem Conotructton Permit Application for a Permit to Construct( . )Repair X Upgrade X )Abandon( ) O Complete System #Individual Components 1 Location Address or Lot No. 11 `��r S Owner's Name,Address and Tel.No. �/ Assessor's Map/Parcel mk Visl 1rT o) v � v V ((((��J r Installer's Name,Address and el.Nc. � �����l��D Designer's Name,Address and Tel.No. i 4� Gtrn R 2MV> Type of Building: Dwelling No.of Bed.-ooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations Answer when applicab ) ►U 67Aa Date last inspecte Agreement: The undersigned agrees to-.nsure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Envirgjqental Code and not to place the system in operation until a Certifi- cate of Compliance has been"s by V alth Signed Date J Application Approved by n Date Application Disapproved for the fo lowing reasons Permit No. .2aa 2-o i Date Issued 7-2y-d'-. No. OZ UU 2 — 0/ 1 j/✓l.� /�c A(/` Fee THE CO MM O WEALTH OF MASSACHUSETTS Entered in computer: ✓v • �' PUBLIC HEALTH DIVISION -TOWN.OF BARNSTABLE., MASSACHUSETTS _ Yes ZIppYication for Mizpozal *p.5tem Construction Permit Application for a Permit to Construct( . )Repair( )Upgrade )Abandon(, ) E Complete System AIndividual Components r Location Address or Lot (No. ,y� � M i` 'Owner's Name,Address and Tel.No. ���,( .�f a� 13 Assessor's Map/Parcel �' `t/`r5W* i �(t L�7/ 1 ''`1'19 .6yvw` , V l ✓ Installer's Name,Address,and Tel.No. '� — �)—if?f 0 Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers(- ?) Cafeteria( ) Other Fixtures ` } Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title *^� Size of Septic Tank Type of S.A.S. Description of Soil; Nature of Repairs or Alterations(Answer when applicanl ) Ito 6 Date last inspected: y Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Enviro ental Code and not to place the system in operation until a Certifi- cate of Compliance has been{issued by i,b alth. ��q�^� Signed �� D Date -C20 e)» Application Approved by Date 1-/7-2C& 2 Application Disapproved for the fo lowing reasons Permit No. ad 2 Date Issued 1-17-2U d'i ————————————— ---——— —————— ————————. THE COMMONWEALTH OF MASSACHUSETTS �?Ua 2 `ol BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY; that the On-site Sewage Psposal S stem Constructed( )Repaired ( )Upgraded( ) Abandoned( )by t 1 l S n at n r5sbaS M 1115, has been constructed in accordance with the provisions of Title 5 d the for Disp osal System Construction Permit No. .2 -0/g dated 1 " 17 a I Installer , [)t,,t 1f.11'Yl ►� � 1 (� Designer The issuance b permit shall not be construed as a guarantee that the sy emwrlfutction a�d rred. ,,✓ Date U�� Inspector �"`�P N No. )a A,) —(l�=T Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Mt!6pooal *pztem Construction Permit Permission is hereby //ra__nted to-C. struct`( �`)�R�epair( )Upgra�-dee�( )A an on( '/1� p� System located at f(D �n 1 t 1!/r'� � (L t S ► ► t/ 7 and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this pe 't. Date: 1 7` 2 001 Approved by i. l� . TOWN OF BARNf ST�ABLE /,L. C, LOCATION SEWAGE # dO _O ` VILLAGE ASSESSOR'S MAP & LOT 04�02,V7 INSTALLER'S NAME&PHONE NO. -Z tj'R G�<��` 1 4301 SEPTIC TANK CAPACITY 1 S00 }'Y1 UX IbUT r\l C LEACHING FACILITY:;(type) 1kll�tLMATd� (%)(size) 65M&S 17 NO.OF BEDROOMS + ,C� t00� IT'S BUILDER OR OWNER 3CT> J � PERMITDATE: I —V'7 -O L COMPLIANCE DATE: I Q6 g 02- 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) Feet Furnished by ?m��s lost) e 5 0001 _o ��Q ,5•�t -� - 7 ,52 j -d TOWN OF BARNSTABLE LOCATION aVc�.64.-E=t���r\ SEWAGE yid VILLAGE NO-ISkUl" (Vl'[kL ASSESSOR'S MAP & LOT eS�O INSTALLER'S NAME & PRONE NO. �W `—c-t� -77 rSQq"l SEPTIC TANK CAPACITY tQ)C� �9-�l_ 0 Ltn Q P-t+ LEACHING FACILiTY:(type)t.(-rpQc-kk"rS (size) 0 C S NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER �.� BUILDER OR OWNER R 6{ DATE PERMIT ISSUED: � DATE COMPLIANCE ISSUED: �'�� ��✓T VARIANCE GRANTED: Yes No �� l4 4 ,e.op (- /.2 A Ac, O ZIOA � A An Mew V) Qo^S' -k-o o 10 PE A Q+v Se G 3 t3 ko Q6X 32 41 �• l r� 4U 0 I 'Ki 5"S 40 FR-t� o� e�� � 36 o ASSESSORS MAP NO:Oly �. PARCEL NO: FEB...... .................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliratiuit for Bi_npuittl Work,5 Tunitrurtiun Verntit Application is hereby made for a Permit to Construct ( ) or Repair ((/) an Individual Sewage Disposal System at: ....f .?...1 .� �r�... ........ -------------------------------------------------------------------------------------------------- Location-Address or Lot No. Ow er ,� Address � --------- 5 - ` '----------- ------ �_ ....l..cJ-.................................. S Installer Address U Type of Building Size Lot............................Sq. feet 13., Dwelling— No. of Bedrooms------------------------------------- -------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons___________.________._____-_ Showers ( ) — Cafeteria ( ) dOther fixtures --------------------------------------------------------------------------------------- ------------------------------------------------------------- W Design Flow............................................gallons per person per day. Total daily flow-...........................................gallons. WSeptic Tank—Liquid capacity/06—galIons 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_-____--_____________-_. 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a - •--••-•------------------------•------___-•---_______-•--•-••----____-•••------••------------•••--•••--•---•------•--•------•------••---•-----------------•-- 0 Description of Soil......................Q..................................................................................................-.............................................. x VW -------- -------------------------------------------------------------------------------------------------- . ture of Repairs or Alterations—answer when applicable._-_- __..__._._�_________dl'fI�CY.�-L.._-._ ,<.�____/ _�� n-tit-�F-``' r S ----.c•��fi�--- {—�ekf_.. -Fss Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compl' nce has been iss e oard of health. Signed . ............... . 8............_........ �. �01S....... .............................. Dace Application Approved By . ....... . ... .. .. . .............--------- .... ... ......... .... .. .. .. _...............-.... ................Dace.................. Application Disapproved for the following reams .................... --------------- ---------------- -- ......... ............................... - _._.......-... - ................. ------- .... Date Permit No. ........ ------------------- Issued ------- .......... . D e THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliratinn for Diipnnal War1w Cnnnntrnr#inn lirrmit Application is hereby made for a Permit to Construct ( ) or Repair (c/) an Individual Sewage Disposal System at: ....�17..._f3.tco .��n---� .. Mn Location:Address ` or Lot No. �L.C...� ----------------•-----------•----- ----------- ......'`-'e-- ----- .................................... Owner dress �l� 1 U Installer Address UType of Building Size Lot............................Sq. feet ., Dwelling— No, of Bedrooms____________________________________________Expansion Attic ( ) Garbage Grinder ( ) 91, Other—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Q' Other fixtures ------------------------------- - - W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity/V_'N_gallons Length---------------- Width---------------- Diameter---.------------ Depih................ x Disposal Trench—No. .................... Width-------------------- Total Length.................... Total leaching'area....................sq. ft. 3 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. 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........................ a •----•-•--•...............................................•-----•-•-•-•••-•-•-•-•-•-•......---------......................................................... 0 Description of Soil.....................................................................................................--------------------------------...._...---------•--••--•---...... x W ---------------------------------------------------------------------------------------------------- . . ...--•-- U I�ature_of Repairs or Alterations—Answer when applicable._._�t`... ..L_!..U-d.�.�?'L....L.........<. ........ . .........................F �� ��5 ...._Of Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compl'ance has been iss e -'board of health. Signed . .. .- ...... - ---- - t -.� �..:...... Date ,,1 U Application Approved BY , r� ..,........ ®. ---/.�tj-'!:ff..............`..�.........v i Y \ Dace Application Disapproved for the following reason .� la -------------------- Permit No. ..._ 1. ` ...'' - _...- Issued ........ ....�.0 -f..J!.._1 ......... ... . .. .. ..._-....ate...... 6) THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Te>r#tftctt#P of Contlaltttn.ce THIS ISO C�TIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( V ) Y t�tdi�t ��(. �f- ------- M at .. .. ... ......� -- - ...- has been installed in accordance with the provisions of TITL .The rate Environmental Code as described in the application for Disposal Works Construction Permit No. - ------- dated _..._........--- .. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT E CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION N SATISFACTO�RY.- ' �J16'r— DATE.... - _...... Insp ecto '+ ...-..... � THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No��i TOWN OF BARNSTABLE -----------------•- FEE.---•--....---•-•-----.. F Binpnnal Workii Tnnntrudinn "ermit Permission is hereby granted---------C Vk...i7.. ------------------------------------------------------------- to Construct ( ) or Repair ) an Individual(Sewage Disposal System atNo......t- == �,••�V-• d to - ----- ----------------------------------- Street as shown on the application or Disposal Works Construction ermit No a •-.__ _.. Dated-------------- ...................... �� /. ........................•....... / Boar`of Health DATE---.....---F----�•---r....... .....r FORM 36508 HOBBS✓!WARREN,INC..PUBLISHERS A.T 6 77- s? � , LUXATION � SEWAGE PERMIT NO. VILLAGE INSTALLER'S NAME & ADDRESS BUILDER OR OWNER DATE PERMIT ISSUED �z 77 DAT E COMPLIANCE ISSUED /(- /77 T!! 1 � No.. ...------- FIzs................................. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH .......................TOWN.--......O F.........BARNSTABLE Appliratiun for Di epos ai Works Tonstrurtiun ramit Application is hereby made for a Permit to Construct (X ) or Repair ( ) an Individual Sewage Disposal System at: Blackstone Road'�Marstons Mills 446 ................_... ................. ---------••-•-•---•--•--------•--------•---- -••.......... .. .......... -•-•••-------•-•---•---••--- Location Address or Lot No. .............. .......1� - -----�x.�Z_....... JY!�l!s ................ Owner Address d a ......................1......•• -- /�•�l__•.-----•--...................---._............--•- ............................ A p/!A...................................................... 000 Installer Address Q Type of Building Size Lot....._____20_�...............Sq. feet Dwelling—No. of Bedrooms__________________________________________Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures ___________________________ _ W Design Flow...............110---___ --___gallons per per day. Total dail flow.._._.._.__330--____________________-dons. WSeptic Tank—Liquid'capacit!_100 Ogallons Len gth8.�__-6��__. Width4...-___Oil Diameter...... .__._ Depth______.-4_�� x Disposal Trench—No_ ____________________ Width__ __.__.____._._._ Total Length............. Total leaching area....................sq. ft. Seepage Pit No....1.............. Diameter...10......_..._ Depth below inlet........§_......... Total leaching area...... 40....sq. ft. Z Other Distribution box (X ) Dosing tank ( ) '—' Percolation Test Results Performed by_c-ape Cod Survey Consultant�ate_____.__.8 .9 �� . • ••• 1._/--------------------. as Test Pit No. 1...2_..........minutes per inch Depth of Test Pit---12___________. Depth to ground water....nOne..... " (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water. Q' !� F M See attached Description of Soil. ............. r ' ©______ xw -•-•-----._,O_r_ 4----- ---= . ----- -•-' -f'S••�- ••--•-------------•••-•..._•--•---•••-••--_•--•- _ --_---. ...-•-------••••••-----•---•-•---------•••----••-••--••-••-•--•--••-•--••••--•-•-•---. AAYLDR..... . v�y,G v s V Nature of Repairs or Alterations—Answer when applicable. •,�-p•No.-23..... �o Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in acc h the provisions of TITS: 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. igne L ' Date Application Approved By........- -4 ........................ ...j- '='��� 7 / Date Application Disapproved for the following reasons_______________•_____....________-_______________..._________________-______________.___.__.______..__...._______ --------------------------------------------•---------•-----....-•-------•--•--------------•-•-----•--•--••-•--•-----•---------------------•-------------••••-•-•••-•---••----------•••••-•-••••-••-••-- Date PermitNo........ -�--•-....•-•-------------•...... Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF' ALTH ................/.. ? ?'✓.......OF.................. Cd!S/? .......................... (In ifirFa#r of Tunt ifi anre THIS IS TO CERTIFY„ That the Individual Sewage Disposal System constructed (a( ) or Repaired ( ) by......... {`--�-cA_111�1..-•---•----------•----•----•.....................•--------------------•-•---------••---..._....---...._......_....----•-------........._..._........-------•-- Installer at.- f C k_!`H U r2/►f---------------1. )- - ------.......N� � ' L� � has been installed in accordance with the provisions of TITLE 5 o The State Sanitary Code as desc 'bed • the application for Disposal Works Construction Permit No.__-_______�T- ______________ da.ted_....................9 _f�_____ THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE........................................•---•-------•--•••-•---•••----••••_..... Inspector........................... ---------------------•-•---••-••................... s No........... �........ Fss....r.�.�.......�4......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .....................TOWN.---.....OF.....-...BARN$TABLE-----------------....--------.............------ Appliraft an for Uiipn,i al Marks Ti n,itrur#ivat prrntit Application is hereby made for a Permit to Construct (g ) or Repair ( ) an Individual Sewage Disposal System at: Blackstone Road'-Marstons Mills 446 .....------•---•---------•-..--"..... f--......... ......... ......... ........ • •Location-Address or Lot No. t tI _1!: t_.41n.p.........•.... ........ A_ _.... .5`_7. t,F•i I.y i ............................... }} Owner Address WlC f•/ -!#/ ................ ......••-----•----•-----•-- Q �� ........... W ••.....................)-.••.. L.................................. M Installer Address a d Type of Building Size Lot.....20_,000 Sq. feet U Dwelling—No. of Bedrooms.......... ................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building No. of persons............................ Showers — Cafeteria aOther fixtures ......................................................---------•-•---------------------•---------•----------------------...........•----•......--•--- d 110 bdr , 330 W Design Flow............................................gallons per -}per day. Total daily flow............................._ ............ Ions. WSeptic Tank—Liquid'capacity.l000gallons Length$.----6".. Width.._.. Diameter...... Depth.. ?----4�� x Disposal Trench—No. .................... Width..........._...... Total Length.........._....... Total leaching area.................... ft. Seepage Pit No----z_____________• Diameter...10___.__._... Depth below inlet...........•........ Total leaching area.....340 sq. ft. Z Other Distribution box (X) Dosing tank ) Gj a ... Surve Consultant 8/9/77 Percolation Test Results Performed by.......P...............................Y...1..............._......-. date__.__._.•----_-----------.............. Test Pit No. 1............_..minutes per inch Depth of Test Pit...12.._..__.__. Depth to ground wat (s, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground w . ......Ali O Description of Soil-.. See attached p an n N .......................... ......... ---•-• . U •••----•-F---------- r+ GZ all_Ll7Y _ ''� c� DAYLQ ... .._ No 23941 x --•--•••••-••-------------•-•...--••••-••---•...-•-••--••---------....--•------------•-....•-• . ......---------- ----...---------•••-••---------•-•••••••-- �' ........ Q��r U Nature of Repairs or Alterations—Answer when applicable........................................... ........ ..... .. A �• Agreement:; The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in a dance with the provisions of TITIZ 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. -�r... igne ..........................................--•---•---•- ................................ ' Date Application Approved By..... ;t'' '`` -ti ''�C` -77.-- Date Application Disapproved for the following reasons--------------------------/___....____._._.__...___..______.__••-•-_--_-_------------....._......__.._........... --------•....................•---•-------------------------•--....---...--------------....-•-----•------------•----------------------------•••--.....--•-•••••••-•---•--•-------•--•-•-•------•-•------- Q .w Date Permit No....... ---------------- Issued...........................................I..- ............ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF IJEALTH ................./.L?2c .......OF................:.. .: e.•. CG........................... (9rdifirFaile of TI-Intliliatnrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) f by------...l ..---•-------------------------•-----•-•---....---•-•------------...........-•-----•-------•-----------------•-------.........------.......----••----•---...... Installer at....J4.C.r t:•-._/LZ-Ac.&P1_2 i.LAl..............fZ.1).........................6�t.4_.u-- ......................................................... has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as desc 'bed in the application for Disposal Works Construction Permit No.......... .--a___ ___________ dated__-.._______._._...._�' /,177--•-- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD O HEALTH ' No... .1_ll__..... hfj.?+�:1....OF................Q -.� �.. ................................... FEE.... Disposal Workii Tons#rudilan rrmit Permission is hereby granted........R._r_....7A) A�.......................................................................................................... to Construct (X) or Repair ( ) an Individual Sewage Disposal System at No... (-------- j-_(!l l.j<'_7`/�!tJ A�.1►f. 9i-1�_------..... � ' `��� 1&� 5. Street p as shown on the application for Disposal Works Construction Permit No O______ Dated_................. a................. .. _ .... . Board of Health ---------- FOATE.---•---------- � -1�R� ? . --------•----•--•--------•--- RM 1255 HOBBS & WARREN. INC.. PUBLISHERS 801L L08 �X�t'i.ICUICF�Vn,ur.x�Mar�,a..u, �ry���vdv.t/ i3 y 3 2•'.PEAST2NE LOAM 6 FILL 12•�MAX, / ..��... - --rr� L O sd Nil ('�,•,•, T—•, DIST. / �, . • ° BOX I• ° °° ,• oo °• QND ,octc O'MIN. 1000 ,24 MIN• ° 0 GAL. I. a 1000— GAL. d o 0I PRECAST OR ° ° °I G SEPTIC 6`10 00 ° ° BLOCK ° °° TANK I�°, SEEPAGE PIT ° u •+ I� �° ' o° o ° o I L 20' MINIMUM , ° °I FOUNDATION e h' Gea•T1 = II 1 %t WASHED STONE y I - iZ'7. 3 lr S�+ownr �tFsA`Q O�ii ccJAS �.o�faTr y Nnr At�ts`� 1 SCALE: 1"_ S " 1=ICI S ' ?tia os! A usi 3t N77 ^NZ>;t I . PQL�C. RAYQ f - I r- I O ` filet Al4's AL kt 4,6 S• TEST BY: 4, QcoItcz, .!/.N•c,te.,t�o.✓ TOWN INSPECTOR: 1 BACKHOE OPERATOR : 1�.ore�- ec�+risitr�� L4iv� 3� ✓off TEST MADE ON 977 O �e ROSERT r F. I DAYLOR M �S1t OF b A • �� ROBERT G F. / DAYLOR / p Mo.23741 STE J / r e- 167 5; % t�j7 ,r 3 o,S XX 4,o oarr�S �o s�lC'TANk /- - � 3—oc7TlrEt' r , 'R av 3 9 4' 139 00 vl- 146 ELEVATION SCHEDULE PROPOSED BITE FLAW L INV. AT FOUNDATION . 2. INV. INTO SEPTIC TANK IN 3. 1 NV. OUT OF SEPTIC TANK ,LdT 446 ^- �ffif�lJ�'S7-O4/S _ �36 93 4. 1NV. INTO DISTRIBUTION BOX - SCALE: I° 5. 1NV. OUT OF DISTRIBUTION BOX = V64'76 C— S(o7 D 6. INV INTO SEEPAGE PIT CAPE COD SURVEY CONSULTANTS ' T BOTTOM OF PIT = l Ste' ROUTE 132 Op HYANNIS, MASS. A DIVISION BOSTON SURVEY CONSULTANTS, INC. B. SOTTOM OF STONE LAYER