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HomeMy WebLinkAbout0026 DOVE LANE - Health 26 DOVE LANE, MARSTONS MILLS PPFA = 013 011 TOWN OF BARNSTABLE LOCATION ,?(g fjlA.2 kayam. SEWAGE# 200-0-i 0 VILLAGE tY\• (V'-,,kk S ASSESSOR'S MAP&PARCEL i3 "� 1 INSTALLER'S NAME&PHONE NO. �21 Y-O 2 8 SEPTIC TANK CAPACITY kp©O '0 to co S t LEACHING FACILITY: (type) Ub ArC 3 6 t to 11 assize) %1 ,s r as. 0 NO.OF BEDROOMS OWNER S�,Co y, t o w c C .L PERMIT DATE: a-12 - Zo/o COMPLIANCE DATE: I S - 1080 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility No IZ 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 C /aQelNe"G�e [sl'>��Zik�( 1-I:L. A2 a 81 OZ 3-7• v 63 4� Lta.o r3 C 3 ��•;s cy 97- 1 Town of Barnstable P# 2 Department of Regulatory Services : WMAIT BLK : Public Health Division Date ! o MASS 16. 200 Main Street,Hyannis MA 02601 Date Scheduled Time I lhl^ Fee Pd. /0) Soil Suitability Assessment for Sewage Disposal Performed By: H yc=ljtc-_( e m e fled, e S Witnessed By: v, LOCATION& GENERAL INFORMATION Location Address Owner's Name S e 61 r '1w J" Al t!I f Address Assessor's Map/Parcel: Engineer's Name NEW CONSTRUCTION f REPAIR Telephone# SVYLas �tbvG -54.9-273-0377 . Land Use 5ui5te Komi( 1 f eS(de:)W" Slopes(%) /(D 'Z 6 Surface Stones Distances from: Open Water Body — ft Possible Wet Area ft Drinking Water Well — ft Drainage Way ft Property Line 7/o ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands fn proximity to holes) SZ� aiF�cl�c cl 'Ail II - Parent material(geologic) aLA*JdaA Depth to Bedrock 7./32 (055' Depth to Groundwater. Standing Water in Hole: /3 211P5 S. Weeping from Fit Pace 7 13,2 t.�' 1, Estimated Seasonal High Groundwater 7/3 2 35 DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: O tle- k 0495e;UQ dim Depth Observed standing in obs.hole: _ �13 2 in, Depth to soil mottles: 7122 in, Depth to weeping from side of obs.hole: 7 l 32- in, Groundwater Adjustment ft. - Index Well# — )leading Date: - Index Well level� Adj.factor,,m� Adj.Groundwater level PERCOLATION TEST bate l.2�-ic�-�c.Thne Observation _ Hole# _ Time at 9" u r, Depth of Perc (ob -78 y Time at 6" Start Pre-soak Time @ jj , l 2M — Time(9"•6") End Pre-soak Rate MinJInch L Z Site Suitability Assessment: Site Passed V Site Failed: Additional Testing Needed(Y/N) N Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the. Barnstable Conservation Division at least one(1) week prior to beginning. Q:\SEPTICIPERCFORM.DOC DEEP.OBSERVATION HOLE LOG Hole# 1 Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. Consistency,% ravel �.Z 2- N Y-2Y 4S /virs/6 5L 7 ,Sp/, t 3 Z -2 rlS 2, 5Y'-/� DEEP OBSERVATION HOLE LOG Hole# 2- Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistencv.%Gravel 2-Y �S ieY� 3/i 411 - DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Cansi ten Flood Insurance Rate Map: Above 500 year flood boundary No_ Yes . _ Within 500 year boundary No Yes Within 100 year flood boundary No, Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? 4t5 If not,what is the depth of naturally occurring pervious material? -- Certification I certify that on 1 27-7�y (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training,experti a and a rience described in 310 CMR 15.017. Date Signature Q:\.S.EPT1CIPERCFORM.DOC • ems\ Commonwealth of Massachusetts Executive Office of Environmental Affairs Dept. of Environmental Protection One winter Street,Boston,Ma. 02108 .John Septic D.E.P. Title V Se Septic Inspector P.O. Box 2119 Teaticket, MA 02536 WILLIAM F.WELD (508)564-6813 Governor r" ARGEO PAUL CELLUCCI f Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ,. o J3 PART A 0/1 CERTIFICATION MqY 2 _` 8 Property Address: 2GDove Ln.MarstonsMills Address of Owner: ,`L� 1998 -� Date of Inspection: 5/19198 (If different) fatf��CFFr d1� Name of Inspector: John Ora Tom O'Roake:P.O.Box 602 Marstons Mills V2648 I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000) 1 Company Name,Address and Telephone Number: t U CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: x Passes This inspection Is based on criteria defined In Title V _ Condition II Pa55C5 code 310 CMR 16.303.My findings are of how the system is y performing at the time of the inspection.My Inspection does _ Needs F th Evaluation By the Local Approving Authority not Impyenywarrentyor guarantee of the longevity ofthe Fails septic system and any of Its components userul life. Inspector's Signature: /G'U� Date: 5120198 The System Inspector shall bmit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. INSPECTION SUMMARY: Check A, B,C,or D: A] SYSTEM PASSES: x I have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. Indicate yes,no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If "not determined",explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of — CoMpliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection; or the septic tank,whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised U27137) One Winter Street • Boston,Massachusetts 02106 • FAX(617)556-1049 9 Telephone(617)292-5500 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 26 Doves Ln.Marstons Mills Owner: Tom O'Roake:P.O.Box 602 Marstons Mills 02648 Date of Inspection:5119199 _ SewoQe backup or.breakout.or. hioh.static water level observed.in.the distribution box is due to a broken. or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if (with approval of the Board of Health). Describe observations: broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced —The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction Is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presense of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method usedto determine distance (approximation not valid) 3)Other D] SYSTEM FAILS: You must Indicate either"Yes"or"No"as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No _ — Backup of sewage in facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters clue to an 0verkittdt-0 or'JougH cesspool. SAS is in hydraulic failure. (revised 04127)871 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 20 Doves Ln.Marstons Mills Owner: Tom O'Roake:P.O.Box 602 Marstons Mills 02048 Date of Inspection:5110/99 D]SYSTEM FAILS(continued) Yes No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Numbers of times pumped Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: The following criteria apply to large systems in addition to the criteria: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 0427197) I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 26 Doves Ln.Marstons Mills Owner: Tom O'Roake:P.O.Box 002 Marstons Mills 02648 Date of Inspection:5119199 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)] (revised 04127)971 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 26 Doves Ln.Marstons Mills Owner: Tom O'Roake:P.O.Box 602 Marstons Mills 02648 Date of Inspection:5119199 FLOW CONDITIONS RESIDENTIAL: Design flow: 220 9 P•d./bedroom for S.A.S. Number of bedrooms: 2 Number of current residents: 1 Garbage grinder(yes or no): No Laundry connected to system(yes or no): Yes Seasonal use(yes or no): No Water meter readings,if avail able:(last two(2)year usage(gpd): rda Sump Pump(yes or no): No Last date of occupancy: nia COMMERCIAL/INDUSTRIAL: Type of establishment: nia Design flow:0 gallons/day Grease trap present: (yes or no) No Industrial Waste Holding Tank present:(yes or no) No Non-sanitary waste discharged to the Title 5 system:(yes or no) No Water meter readings,if available: nia Last date of occupancy: We OTHER:(Describe) rig Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: pumped two years ago. System pumped as part of inspection: (yes or no)No If yes,volume pumped:0 gallons j Reason for pumping: rda 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: 14 yrs.old Sewage odors detected when arriving at the site:(yes or no) No (revised 04127)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 20 Doves Ln.Marston Mills Owner: Tom O'Roake:P.O.Box 602 Marstons Mills 02648 Date of Inspection:5119199 SEPTIC TANK: x (locate on site plan) Depth below grade: 0" Material of construction:x con create_metal_FRP_Polyethylene—other(explain) If tank is metal, list age nia . Is age confirmed by Certificate of Compliance No (Yes/No) Dimensions: t.e16"H67••w4•10" Sludge depth:10" Distance from top of sludge to bottom of outlet tee or baffle: IT" Scum thickness:" Distance from top of scum to top of outlet tee or baffle:e" Distance form bottom of scum to bottom of outlet tee or baffle:e" How dimensions were determined: measured Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,etc.) Septic tank and all components are structurally sound and functioning property.Recommend pumping now,then every two years. GREASE TRAP: (locate on site plan) Depth below grade: n1a Material of construction: _concrete_metal_FRP_Polyethylene_other(explain) Dimensions: nra Scum thickness:rda 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: Ma Date of last pumping;v. 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.) nla BUILDING SEWER: (Locate on site plan) Depth below grade: e•• Material of construction:_cast iron x 40 PVC_other(explain) Distance from private water supply well or suction line." Diameter: 4• Q;mments: (conditions of joints,venting,evidence of leakage, etc.) I Irevieed 0412Tl87) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 26 Doves Ln.Marstons Mills Owner: Tom O'Roake:P.O.Box 602 Marstons Mills 02648 Date of Inspection:5119f98 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: rda Material of construction:_concrete_metal_FRP_Polyethylene_other(explain) Dimensions: rde Capacity: rda gallons Design flow: rda allons/day Alarm leve'I:_rda Alarm in working order?_Yes_No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) rda DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: Na f Comments: (note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box etc.) rda PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no)No Alarms in working order(yes or no)_Yes Comments: (note condition of pump chamber,condition of pumps and appurtenances, etc.) rda (revlaed 04l27)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address. 28 Doves Ln.Marstons Mills P Y Owner: Tom O'Roake:P.O.Box 602 Marstons Mills 02648 Date of Inspection:5119199 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: one 10DO gallon leach pit leaching chambers,number:Na leaching galleries,number: Na leaching trenches,number,length: Na leaching fields,number,dimensions:Na overflow cesspool,number:nla Alternate system: Na Name of Technology:_Na Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.) Leach pt and all components are structurally sound end functloning properly.There is nowt'or leaching left In the ayatem. CESSPOOLS: (locate on site plan) Number and configuration: Na Depth-top of liquid to inlet invert: Na Depth of solids layer: nda Depth of scum layer: Na Dimensions of cesspool: Na Materials of construction: Na Indication of groundwater: r" inflow(cesspool must be pumped as part of inspection) Na Comments:(note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation, etc.) Na PRIVY: (locate on site plan) Materials of construction: Na Dimensions: No Depth of solids: Na Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.) Na (reviesd 0412T)9T) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 20 Doves Ln.Marston Mills Tom O'Roake:P.O.Box 602 Marstons Mills 02048 5119198 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) r � �6 �rc•f\� Page P of 10 (reviesd 04)27197j A SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 26 Doves Ln.Marstons Mills Tom O'Roake:P.O.Box 602 Marstons Mills 02648 5119198 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 x Use USGS Data Describe in your own words how you established the High Groundwater Elevation.(MUST be completed) USGS maps and charts A (rwbsd04)2719T) page t0 of 39 c L LOCATION SEWAGE PERMIT 00. VILLAGE INSTA LLER'S NAME & ADDRESS C BUILDER OR OWNER 6 Fa yC L< e DATE . PERMIT ISSUED DATE C0MPLIA- NCE ISSUED G - � � �.r t � � .. �. '� � .. �� ��, is- iz � :� No. ..�� ; ..... Fxs. .......................... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ...........................................O F......................................---------•............................-------------. Appliration for Dispaii al Works Towitrurtion Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ......... ....2 ._�D aV .......--.L.Al. ............................... G 8T__ .... C! ....1.3.......... l.!> Location-Address or Lot No. !dl l�[./A-M 131.. 1 Ar.!!li ... ®�f..Q.1Qo�U.c.. •33..W-�5TWa0 �JZt......LEST F..{, 1.�.......Mt. Owner Address a ----•-•--•--•------••-••.... :? ........................................... ..................•-•-----••......... .........._. Insta ler Adflress dType of Building Size Lot.................... .....Sq. feet U oms......_.... ___________________.Expansion Attic Garbage GrinderDwelling—No. of Bedro (. ) Other—Type of Building ....W..100D......... No. of persons...........Z............. Showers (4O — Cafeteria ( ) Other fixtures ----------------------------------•--•----------•- W Design Flow....... 2.....1.1.0_...........gallons per person per day. Total daily flow....... .3-0........................gallons. WSeptic Tank—Liquid capacity..l�JMC 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........................................ aTest Pit No. 1................minutes per inch Depth of Test Pit....--.............. Depth to ground water........---............. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a . ODescription of Soil........................................................................................................................................................................ x Z --••-------•----------------••-•••••-••••-••-••-••-----------•••••---------------------••-•-•••---••-----•-••-•----------•-•••-•...----- U 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 TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate o ompliance has been issued e bow of th. Signe '� - ......Y- te Application Approved B .... .... ..........---•-•-------•--•---•---•-•••---•-• .................................. -.-----1 Y ---------•--- Date Application Disap ve o e following reasons:-----•-------------------------------------------------•--------------------------------------------------....-- ......•• •-•••-•---•-•••--•••-•---•••--••-•-•••--........--•---•----•-••--•-•-----•-••-•-------•---•-•---•-•--•..............................•-- -----•......-- Date PermitNo......................................................... Issued....................................................... Date Y THE COMMONWEALTH OF MASSACHUSETTS *• BOARD OF HEALTH ...........................................OF.......................................................................................... Appliration for Disposal Works Tonstrn.rttnn tr ttit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ...........a�_. :.... �n.......... zr s �s.J'h�lls ..........�3 Location-Address or ID. .................................................... Owner Address W Inst ler Address � Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms.............................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ---U)PP D......... No. of persons..........a.............. Showers (X) — Cafeteria ( ) P4 Other fixtures ----------••... -••--•-•-•--... . W Design Flow.........//0..........................gallons per person per day. Total daily flow---�-'.3Z?............................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter...----..--..... Depth................ 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 ( ) Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. 1................minutes per inch Depth of Test Pit...........--....... Depth to ground water.....-----.............. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.................:...... •---•-•-•----------------------•---•----•---------.......................................................................................................... 0 Description of Soil........................................................................................................................................................................ x U ..............•----•--•••••••-•••-•-•--•-••----•-•---•...•-•-•••-•--••--•-.....•-•......---•••••...._........----•-••••---••-••-••------------•-•-•-•--......•-•---...........----.......---------••••. W ----------------------------- ---•----•-•--•--•-•-•------•-•--------•-----------•-•••--•--••--•---•------•--•-•--•---------------------••---•••---•-•---•-•••••-----•----•-••-•-•-•...........-•---•••-- U 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 TIT111, 5 of the State Sanitary Code— The undersigned urther agrees not to place the system in operation until a Certificate'of ompliance has be ied�th bo d ealth \ Signe ..........................•-- -• -• ... ..................................... .- �/ to Application Approved B ...... ... -....--•••---•-•-•••••....... ........................................ ••-- -••- . ---- Date Application Disappr ve ,fort a following reasons:................................................................................................................ .............................• ------;V. -------•-•••.....--••--------•-•••---•--•.._..__...-•-----••-•----••--•••--•-•-----------••--••...--------••-•-•-••••-•...----•----•-----•----...--•--- '� Date PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HE LT ....................OF...... .E. ...... ...................................... (Intif irtt#r of Toutpliattrr THI TO TIFY hat he :vidual Sewage Disposal System constructed ( or Repaired ( ) by-----••-- A..--- ........... •-•-----------------•------•----•----••----------•----------•-----..........---...---...--•--•---••---••--•-- Installer t - at ................ - ........... ------'-.......................................................................... has been in talled in accordance with the provisions of TITLW 5 of The State Sanitary Code 0.dys in the application for Disposal Works Construction Permit No.... ...f�2 . --------••-• dated .1 THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED A GUARANTEE THAT THE SYSTEM WIL FUNCTION SATISFACTORY. 11 DATE....�l�._...................................................•......-•--_. Inspector....-- .................................................... THE COMMONWEALTH OF MASSACHUSETTS BOAR M__H ,!:�.�.........................OF.... .. ....... - ........................................ FEE.. J� . ............. Disport � Juan r mi# Permission is reby granted.---0-= ------ ------- --•--------......-----.......-•------•-------.........----..................------ to Construct ( V 5o12epair (f/ an Individ 1 Sewage Disposal System 4 ��* ' at No.- .. dssr...: - tr -----•-•--•-•••-- .....------. ••-•-• ---••• . •-•••----•...... Street y. as shown o/the plicat' n for Disposal Works Construction Perms N ''. -:_.....__._. D d.:3 .Z..�7. ...................... 'i DATE....l ............................................ Boar of Health FORM 1255 HOBBS & WARREN, INC., PUBLISHERS „Slt..t�et_� �tuntt_� - 3 �st.�tzooM c,lo A2I�AGE &IZI art✓r__tZ. \�Z• ti ;rLow c_ Ito V. St Sgp G.PM ,0 ` t�E-3�tG 'T"At.tIC 6S30� (�C N.• ��i ey.P.D. 04- I' . a-1 t \oWt on I�PosAL_ PtT u-.E. loco (Gd_, "� vC>/ 1�'. ►cq (DF-WQu- A�� - l`gyp S r. ,� 1Gp•'�- � �` ` �' Ic�p SF .c 2.S • S 7S I �1 $orT-mAA ACEA: So St=. Sc'P Tl_ 40 fb �J yam-. ) 1 .o L Sb G.PV. TOTAL 1PG:Gtd-Q t 425 G•PD. Tt>T,n t_ IDAt L%f 1=c.ow t Vt=~f1G�t�T1otJ LZI�TE : < to Smi 0' oiz �Sv i .�.•�.�,�,;9 � •tea' U 6.• 1 V �P �* V 108.6, Wei t��--5 � �IUD e O rt-�.,,-..»•._.�•• .-c:--i��� � r P� - f�. '�CL' I ood •?� 4'poa n►sr iW. GAL. _... f pox i 0!5,C Sc-vnc q Gnt.. 104,C. : ` L"4i4 s PIT q s STourr_- Icam,¢ 0. . : : _. . CECTIt=1ED p1.0'i” �L.l.Lhl'• P1zo�1�.� i LocATID" MAFSTOU I�tt"t.S —0- • pL.A ti.1 RL 1=c�E 1.!CE. 1 GGtz-riF 4 TkAT TNE. t' ► a:uLSUo�ct�►1 N E:C'L"-ova Gc v�PL�IS \;/1 TK TO:: 51 V E t_t l -oT 13 AIJr-> SC-TL,.ACK j:C47utrG.M&WTS OF TNt -rowU Act) IS �i P K 2e4- Pke-�E `t 1 LOCATEb- WI•r%41►.1 "Tt r-- KLOob PLAtQ- bAT�� 4,81 6/S.)CTCtiZ �. u�E 1�lG. } .� RCGIsf'�:.tZED t�l�a �;uev�Yoct 1 e, V OT EAS C'a D;TEr_Vtt lz-_ o MAS�i� 11JsfC'c1MC_Wi �,uc:.i�Y T►1L cat=C,�T�. ,14c.&J .a At'c',t_1C&. �- lT