HomeMy WebLinkAbout0011 DEER HOLLOW ROAD - Health 11 DEER HOLLOW ROAD, MM
A=031-015
i
/qN. �3 r TOWN OF B.AMSTABLE
LOCATIONOEQ
SEWAGE #
VILLAGELLL� ASSESSOR'S MAP&LO
INSTALLER'S NAME&PHONE NO
SEPTIC TANK CAPACITY b
LEACHING FACILrrY: (type) (size)
NO.OF BEDROOMS
BUILDER OR OWNERLP, , �
PERMITDA COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility &A 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 facili Feet
Furnished by
A;z
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A
90
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No. Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUS TTS
01ppiicattou for 33izpoai *rwm Con.5tructton Perm'
Application is hereby made for a Permit to Construct( )or Repair( an On-site Sewage Disposal System at:
Locati n Address or Lo No. pwner's N e Address and TIN
WOU-) Qvs kilh1w
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Garbage Grinder(M
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
Description of Soil
N,a�lt�ure of ReBairs or Alterations(Answer when applica le)-ftbf) tV la-W
Date last inspected:
Agreement:
. The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been is by TIS Bo f He h.
Signed Date
Application Approved by
Application Disapproved for the follo ' g reasons
Permit No. Date Issued
No. !!y " Fee
_ THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHU ETTS
01 licatiou for g Otal *p$tem �Con!6tructiori erm
r
Application is herebymade for a Permit to Construct( ' )"or Repair( an On-site Sewage Disposal System at:
Location Address or Lot No. wner's Name Address and TON
.N Q— V13
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
11. Q escr -�
Type of Building:
E Dwelling No.of Bedrooms Garbage Grinder(�
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow H 'gallons per day. Calculated daily flow gallons.
I Plan Date Number of sheets Revision Date
Title
Description of Soil
Nature of Repairs or Alterations(Answer when applica le) ft Q
f i j
'( 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 C rtift-
cate of Compliance has been ise4,,by is Boar f He h.
Signed Date
Application Approved by
't Application Disapproved for the follovqg reasons
Permit No. / - Date Issued
` f,
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Certificate of Compliance -
t ' THIS TO CERTIFY,that Pe.. n-site Sewage Disposal System installed( ')or repaired/replaced( �on
Np l L� y ja_k V--C'Y-^ 4N-iA J for
as has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. dated_
Use of this system is conditioned on compliance with the provisions set forth below:
27 �. ,..
i
No. Fee
f
THE COMMONWEALTH OF MASSACHUSETTS
4
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
X0it� - stem Construction Permit
Permission is hereby granted to
to construct( )repair( t-jin On-site Sewage System located at LLCS'w WQ
i
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.
All construction must be completed within two years of the date below.
F Date: I - ? 7i - f7 Approved by
I
i
f
t /
CERTIFICATION OF SKETQUAND APPLICATION FOR A DISPOSAL
WORKS CONFURUC ION PERMff(WITHOU'I'DESIGNED PLANS)
l hereby certify that the application for disposal works
construction permit signed by me dated Q concerning the
property located at P�Q 4a�'
�-1 t i.meets all of the
following criteria:
• There are no wetlands within 300 feet of the proposed septic system
There are no private wells within 150 feet of the proposed septic system
• The observed groundwater table is 14 feet or greater below the bottom of the leaching facility
• There is no increase in flow and/or change In use proposed
• There are no variances requested or needed.
r
SIGNS DATE:
96
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
(Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
;.
Job
r t
�7 eJ
913 TOWN OF BARNSTABLE
LOi A,TION /L �� fyl� / SEVAGT#
VILLAGE /�AiPS�OyIc� yl��'/,�5 AP & LOT
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY 0 vo e.41
LEACHING FACILITY:(type) ZP4eh f, (size) &Ov�� T
NO. OF BEDROOMS PRIVATE
J /WELL OR PUBLIC WATER fub/-e l),g
BUILDER OR OWNER 1_,9W een e 2 J'/; � e aral?&k s��e�J►✓.�e���n�
DATE PERMIT ISSUED:
DATE . COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
..i=U�N����.°� .may �`_.._- ,,cam c.�s� C�s�w,g �,,y►,n �)
� � o
I
TOWN OF B"NSTABLE
LOCATION 11 HoLtvi✓ A9 fit. &i«s SEWAGE#
VILLAGE k71h?5r1,4,,s 167/1-41 ASSESSOR'S MAP&LOT 4:;!3/
INSTALLER'S NAME&PHONE NO. e—,YV-e-,,et
SEPTIC TANK CAPACITY
h
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS 3
RUffiDER-OR OWNER G;l�. G✓9cv/'�,s.�rz P L�f��v�
PERMITDATE: — COMPLIANCE DATE:
;l
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by 2��
pDRc!a
F
H �RcN
a
J111
CERTIFIED SEPTIC SYSTEM REPORT RECEM M
FEB 1 1995
HEALTH DEPT.
TOWN OF BARNSTABLE
LOCATION
11 DEER HOLLOW RD .
MARSTONS MILLS, MA 02648
MAP 031 PARCEL 015
PREPARED FOR
OWNER
MR. & MRS. LAWRENCE P . LEGRAND
11 DEER HOLLOW RD .
MARSTONS MILLS, MA
BUYER
NONE
PREPARED BY
HILLIARD HILLER
P .O. BOX 250
CENTERVILLE, MA 02632
508-778-1472
1
A
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Department of
Environmental Protection
William F.Weld
Goamor
T> rud
. EA ' .
Devid 0.Struhs
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: l 11�'EQ. f/OGLOc✓ Ro Address of Owner:
Date of Inspection: 1�jcf�9G of different)
Name of Inspector.
Company Name, Addr�slLL/and Telephone Number: opa doX a
14910111 . OV63X
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
_ Passes
Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
j/ Fails
Inspector's Signature: 2_,nlrl� Woe
Date: 1/a �JyZ
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspection. If the system is a shared system or has a design flow.of 10,000 gpd or greater, the inspector and the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner ano copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B,C,oy9
A] SYSTEM PASSES:
�//
1 have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
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, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as
approved by the Board of Health.
(revised 6/15/95)
One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 a Telephone(617)29 ,%W
Printed on Rwyckd Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: // /�vLG ow "4�O ��9/ISTd.�s i'1/GGs'
Owner: s-1 f y Lilu/�QL�G� Ll'GCg�O
Date of Inspection:
61 SYSTEM CONDITIONALLY PASSES (continued)
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the
Board of Health):
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
_ The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
_ Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
_ The cvstem has a septic lank and soil absorption system and is within 100 feel to a surface water supply of Uibulary to a
surface water supply.
_ The s%-stem has a septic tank and soil absorption system and is within a Zone I of a public water supply well.
_ The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
_ The systen, has a septic tank and soil absorption system and 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 presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5
ppm.
DJ SYSTEM FAILS:
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.
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
(revised 8/15/95) 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner: -Vi/,y
Date of Inspection:
D)SYSTEM FAILS(continued):
S�Pric is�,r�r,
l� Static liquid level in above outlet invert due to an overloaded or clogged SAS or cesspool.
i
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).
Number of times pumped
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E) LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
The design flow of system is 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:
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone 11 of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 8/15/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: // •DEC HaGGvrr/ Rp .�i/�/IS?c7,vs �iGl�S ,
Owner: �i/,.� G✓JuiiP,+r,�Gn 'O, GyG,Gy,vJ/
Date of Inspection:
Check if the following have been done:
,ZPumping information was requested of the owner, occupant, and Board of Health.
lone of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
lZAs built plans have been obtained and examined. Note if they are not available with N/A.
!/The facility or dwelling was inspected for signs of sewage back-up.
r,- he system does not receive non-sanitary or industrial waste flow
`The site was inspected for signs of breakout.
:'All system components,Wcluding the Soil Absorption System, have been located on the site.
1/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.
P"The size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
vThe facility ov nor (and occupants, if different .'rem owner) were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 8/15/95) 4
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM'
PART C
SYSTEM INFORMATION
Property Address: // OEM RvLLow RO,
Owner: �i�.ri L✓?w/l�.-�'.� /� GC G.CA,v�
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow:a /,:_gallons
Number of bedrooms: 3_
Number of current residents:
Garbage grinder(yes or no):��
Laundry connected to system (yes or no):-8y
Seasonal use (yes or no):LVU
Water meter readings, if available:
Last date of occupancy:
COMMERCIAUI NDUSTRIAL:
Type of establishment:
Design flow:_gallons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non-sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings, if available:
Last date of occupancy:
OTHER: (Describe)
.Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as part of inspection: (yes,or no)_/O
If yes, volume pumped Qallons
Reason for pumping:
TYPE 9F SYSTEM
r/ Septic to absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes,attach previous inspection records, if any)
Other(explain)
APPROXIMATE AGE of all components, date installed (if known) and source of information:
Sewage odors detected when arriving at the site: (yes or no)
(revised 8/25/95) 5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C.
SYSTEM INFORMATION (continued)
Property Address:
Owner: /`;/^ "0'
Date of Inspection:
SEPTIC TANK: k-"
(locate on site plan)
Depth below grade:
Material of construction: 4.,eo'ncrete_metal _FRP—other(explain)
Dimensions: f7 X `1'8 o S % a 64
Sludge depth: /O11 - w/15 je'sT
Distance from top of sludge to bottom of outlet tee or baffle: ;73—'<
Scum thickness: O
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
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.) ovTLXT
G✓/95 .�/IG 3 " ve,,,t;P !-g/ 4 i.o 64'fine5 SST ri io. i�
fi14z,o 4A,.vE'4 T&X T XS GG�.O ^e--e Tff.E X/A,�s 4-y4,<z ifG.�iG�Yr
°� �2 •� �� n L G. !/4 .9/G.CJ oy LsEi9 b'si GE.
GREASE TRAP:_
(locate on site plan)
Depth below-grade.
Material of construction: _concrete_metal _FRP—other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of -rum t� bottom of o0et tee or Dance:
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.)
(revised 11151151 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property yAddress: /ex iQo
�i�45Tur�s' s�/GGS
Owner: h/.y /G, G.c GdA,vo
Date of Inspection:
TIGHT OR HOLDING TANK:_— '
(locate on site plan)
Depth below grade:
Material of construction: _concrete metal_FRP other(explain)
Dimensions:
Capacity: Qallons
Design flow: Gallons/day
Alarm level:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:=
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and d;s;ributic-. :s eq !, evidence of so!id! carryover, evidence of leakage into or out of box, etc.)
PUMP CHAMBER:_
(locate on site plan)
Pumps in working order:(yes or no)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 8/15/95) 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: /1 b� l. H 2Q �QSTv�s Owner:
Date /�'�/i•� L✓!Gd/lL,vc,,c /� (.LG,Q.�,Gp
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS):
(locate on site plan, if possible;excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type:
leaching pits, number:L
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) -
TI',4 4/er.?vio 411f 5 /¢P�is'OX/hitTEL y
A Nndo L�U.t� Gd�fs vS� i9�vo � omits d,�rl�.rtriu.� ?fi'.1r Tt,%E ci4uio
CESSPOOLS: _—
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer.
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow (cesspool must be pumped as part of inspection)
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
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.)
(revised 8/15/95) B
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: // �EC.� �� iQp 0*1e
Owner: A,1.y
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks.or benchmarks
locate all wells within 100'
Jam,
C•
po Rc H
/3flG
�.pEc K
yvP/�o�U
1 I i
� I poRc y
— i
� ou�'RHAvG I
DEPTH TO GROUNDWATER
Depth to groundwater: 2�/ feet
method of determination or approximation: _?_t1k
i L T;Vz-lf i 1- r,�E vs�c A 1vsr rr� r f sa�v s3
_3,,&E G /s y 7, G>S //.E S/? _
LriflS 3,a s' % c�v/L/t fJ,y� Ass di►,� � G' D�,e� �iT .
(revised 6/15/95) 9
c� 3
No. T
— Fee�_
THE COMMONWEALTH OF MASSACHUSETTS
TT
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE S MASSACHU3
01pp[ication for Migpooar *pment Construction Verm"
Application is hereby made for a Permit to Construct( )or Repair( an On-site Sewage Disposal System at:
Locatian Address or1,oS No. wner's N e Address and T N
11
Installer's Name Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms 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
Description of Soil
Nature of Repairs or Alterations(Answer when applica le)
N
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 aIt;
cate of Compliance has been is by is Bo f He h. 22
Signed Date `J
Applicat
ion Approved by
Application Disapproved for the folio g reasons
Permit No. Date Issued
---------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Certificate of Compiiance
THIUQAz TO C TIFY,that n-site Sewage Disposal System installed( )or repaired/replaced( Ion
�zQ by ,(L` fLzryy\ for
as has been constructed in accor ance
with the provisions of Title 5 and the for Disposal System Construction Permit No. - dated
Use of this system is conditioned on compliance with the provisions set forth below:
Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Construction J)ermit
Permission is hereby granted to
to construct( )repair( t-ran On-site Sewage System located at LLC3�-u
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.
All construction must be completed within two years of the date below.
Date:_ �, - 9(� Approved by ,
;�... V
I
No........................ .........
THE COMMONWEALTH OF MASSACHUSETTS
II®0� BOARD OF HEALTI�-
���- ��ST�laGC
C� - -- ---------of ...... ................... .. .......................
Appliration for Di iVuual Works Tonutrurtiun Prrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
(( La r- . 3 h' �9l4ltSl�d� ,�ii�G
-------------------------------------------------------------------------------------------------- -•----...._.....•---•-•---••------••------•---....................------------5
oca'on-Address or Lot No.
...../?:.._..... 'e `v-------------------------------------- ----------------q0-=--------��f -Y-.....k 14'4.... s-
Owner Address
P4 Installer Address
d Type of Building Size Lot----------------------------Sq. feet
U Dwelling—No. of Bedrooms......3.................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building .......................... No. of persons...................--.....-- Showers ( ) — Cafeteria ( )
a' Other fixtures ............................
W Design Flow.........Jy:,d................_ gall NWr.person per day. Total daily flow.......Jja 2.......................gallons.
WSeptic Tank—Liquid capacity all is Length................ Width................ Diameter-.----------.--. Depth..--..--......-.
x Disposal Trench—No 1�th- ----------------- Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No....IdL1j_ iamel'er.................... Depth below inlet.................... Total leaching area------------------sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date--------------------------------------
,� Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.........._.....-_.-.---
0� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.._....__...._..--------
0 Description of Soil............................................---........ --
x /1, �/ - -
w
UNature 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 Article XI of the State Sanitary C e—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been sued by the b ealth.
Signed--- -- - ...... . .. ......... -
- ----------- -------------------------------
Das 7
Application Approved By--------------- / - 6 /
------------------------------------------
Date
Application Disapproved for the f of ing reasons: '
-•---•-------•-••-------•---•---•----•••--•-•---------••-•-•----•-------••---•-•---•--•--•••-•----------------•--•--------....---•-••---•---•--••------------•---•----...---------•--------------------
9 / -•----_•?••••Date
PermitNo......................................................... Issued.---f 2f a :...........
THE FOLLOWING
IS/ARE THE BEST
IMAGES FROM POOR
QUALITY ORIGINAL (S)
I m �C&'
7�
DATA
.................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OFF HEALTH
_ ..........................OF.......................`............... -----------------------=•-......------------•-•
Appfiration for Biivl sal 10orkii Tomitrurtion Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
Le r
....................................... .r .._.............. .___--_..__......_ ............................_...................................................." ----_-_---
j3�Locatiorn-Address or Lot No. _
---•-- -------r---------• ..tl 3 4` Dry -...........................Z ` -------! -- �-------= = ---..
yr Owner Address
Installer Address
PQ
VType of Building Size Lot-__--_____________________Sq. feet
Dwelling—No. of Bedrooms.__.....................................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of•Building .......... No. of persons Showers —
P-I YP. g ---------•-•------ P'- ( ---)•------Cafeteria ( )
Otherfixtures -------------------------•---••------•-•------••----------••---...---•---------------•--•----•--............. ._....
W Design Flow-------- ..........................gallons,per person per day. Total daily flow...___ �'__r%___________________ ___gallons.
WSeptic Tank—Liquid capacity f- -gallons Length................ Width...... ..._ --- Diameter---------------- Dept]l................
x Disposal Trench—No. .........z..a..:_.e/dth.................... Total Length.................... Total leaching area--------------------sq. ft.
Seepage Pit No.___Z J�r>.' ia�� Dmd"ter.................... Depth below inlet.................... Total leaching area------------------sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date----------------------------------------
,� Test Pit No. 1................minutes per inch Depth of Test Pit-................... Depth to ground water__-_-_._----__--_---._.
(ZI Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water..-.__--_________-_-___.
a -------------------- --•-----------------------------------------------------------------....------.-------------•---------------------.....................
0 Description of Soil........................................................ ----•--•-- �-
a ��
UW ---------------------------------•------••--..........•-----------•-••••-••••----•-•--•--•......-f..............................................................I--•--------------------•-------------
Nature of Repairs or Alterations—Answer when applicable------------------------------------------------------------------------------------------------
......................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Cpde— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has•been,issued by-the boardof..health.
Signe ;,.
Dade
Application Approved BY
Date
Application Disapproved for the following reasons:-��._._______
-------------------------- ----------------------•-------------•---------- --------------
--•-----•---------•--------------------------•---------•----------------•--------------------------- -...------------------------------------------------------ ----------------------------.----
/ Date
Permit No........................................................... Issued.... .Z z fir:' ---•-------.
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
,.. .....................OF.
Carr#ifira#r of f 'Ump aurr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired ( )
by ` / d"y - ;f:..' "` -- - - -`----------------------`-"•-`T -- •..........
• ,- *, �r Installer
� xe.
has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No---------4-_ ............. dated-------------------..'-..:-___`_: '.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION, SATISFACTORY. j
DATE ............................... Inspector .........................................................
-�^
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.............................
No.-•----•- ;......
FEE........................
Permission is hereby granted_.._...�:7___+_........ :j:' '{fi
to Construct ( .) or Repair ( ) an Individual Sewage Disposal System
_ .
Street e_ _ a r _
as shown on the application for Disposal Works Construction Permit No.___,_=._ __?':-- -: Dated____::__.__:.__.!............................
.................................... _._......"y, .-----..
• LL_
j 7 Board of Health /='r
DATE...... '? �" ............................. *'d
E.
FORM 1255 HOBBS & WARREN, I,NC.. PUBLISHERS -
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