HomeMy WebLinkAbout0084 EMERALD LANE - Health i
84 EMERALD LANE, MARSTONS MILLS
A=046-044
� � t
CO.M.1,20'N'WEAL,TH OF MASSACHUSETTS
EhECL'TIVE OFFICE OF ENVIRONMENTAL AFFAIRS
= F DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET. BOSTON MA 0210F i617i 292-550v
TRUDY CORE
Secretan
ARGEO PAUL CELLUCCI DAVID B. STRL'HS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 84 Emerald. Lane , Name of Owner T im':Ktnski
Near s t ons M Y l l s Address of Owner:
Date of Inspection: 4/"e—6-0
Name of Inspector:(Please Print)Wm. E . Robinson Sr .
I am a DEP approved systerq inspector rsuant to Section 15.340 of Title 5(310 CMR 15.000)
Company Name: Wm. E . Robinson Septic Service
Mailing Address: PO Box 0 9, Centerville , YIA
Telephone Number:
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
Fails
Inspector's Signature: fill I Date:
The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)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 tfte
system owner and copies sent to the buyer, if applicable, and the approving authority.
NOTES AND COMMENTS
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+ 4
0140F 20o/1
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revised 9/2/98 Pagclof11
N \
`J Pr.rted on Recgdrd Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
'roperty Address: 84 Emerald. Lane , Marstons Mills
Jwner: Tim K ins k i
Date of Inspection:
INSPECTION SUMMARY: Check,) B, C, or D:
A PASSES:
1 have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure
criteria not evaluated are indicated below.
COMMENTS: ,
t
B. S STEM 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.
Indicate y ts, no, or not determined(Y, N, or NO). 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 complying septic tank as
approved by the Board of Health.
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
revised 9/2/98 Page 2of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 84 Emerald, Lane , Marstons Mills
owner: Tim K in s k i
Date of Inspection: il-`_g
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 IN ACCORDANCE WITH 310 CMR 15.303(1)(b)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 surface water
Cesspool of privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
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 AND SAFETY AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system
Y P p y (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 soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS 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 presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm. Method used to determine distance (approximation not valid).
3) OTHER
revised 9/2/98 Pagc3of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 84 Emerald. Lane , Marstons Mills
owner: Tim Kinski
Date of Inspection: Zl— 6'L9
D. S TEM FAILS:
You mu s indicate either "Yes" or "No" to each of the following:
F ave determined that one or more,of the following failure conditions exist as described in 310 CMR 15.303. The basis for this
d ermination 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 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.
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).
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. LA GE SYSTEM FAILS:
You mu t indicate either "Yes" or "No" to each of the following:
The following criteria apply to large systems in addition to the criteria above:
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 o ner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office f the Department for further information.
revised 9/2/98 Page 4of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART 8
CHECKLIST
Property Address: 84 Emerald. Lane , Marstons Mills
owner: Tim K i ns k i
Date of Inspection:
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes Z/ No
Pumping information was provided by the owner, occupant, or Board of Health.
— None of the system components have been pumped for at least two weeks and the system has been receiving narmal flow
rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection.
_ As 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.
✓/ _ The system does not receive non-sanitary or industrial waste flow.
✓ _ The site was inspected for signs of breakout.
�/ _ All system components,excluding the Soil Absorption System, have been located on the site.
✓ _ 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.
The size and location of the Soil Absorption System on the site has been determined based on:
t
_ Existing information. For example, Plan at B.O.H.
_ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable)
(15.302(3)(b)]
_ The facility owner (and occupants,if differeru from owner) were provided with information on the proper nwintenanc f
Subsurface Disposal Systems.
revised 9/2/98 Page 5of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
'rop"Address: 84 Emerald. Lane , Marstons Mills
Owner: Tim K ins k i
Date of Inspection: �`�, cr-&
FLOW CONDITIONS
RESIDENTIAL:
Design flow:Q f O g.p.d./bedroom.
Number of bedrooms(design):, Number of bedrooms (actual):
Total DESIGN flow �Sio
Number of current residents:�i
Garbage grinder(yes or no): A,00
Laundry(separate system) (yes or no)iL 6; If yes, separate inspection required
Laundry system inspected (yes or no)
Seasonal use (yes or no):/L D
Water meter readings, if available (last two year's usage(gpd): 1999 66, 000 gal.
Sump Pump(yes or no):ii+ '0 1998 72, 000 gal.
Last date of occupancy:
COMMERCIAL/INDUSTRIAL:
Type of stablishment:
Design fl w: qpd ( Based on 15,203)
Basis of sign flow
Grease tr p present: (yes or no)_
Industrial aste Holding Tank present: (yes or no)_
Non-sani ry waste discharged to the Title 5 system: (yes or no)_
Water m ter readings, if available:
Last dat of occupancy:
OTHE . IDescribe)
Last d of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as part of inspection: (yes or no)-&
If yes, volume pumped: gallons
Reason for pumping:
TYPESYSTEM
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)
I/A Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components, date installed(if known)and source of information: ��-
Sewage odors detected when arriving at the site: (yes or no) d
revised 9/2/96 Page 6(if 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(contirwed)
'ropeny Address: 84Eiiiarald.Lane , Marstons Mills
owner: Tim K ins k i
Date of Inspection: 41:-
BUILDI G SEWER:
(Locate o site plan)
Depth bel w grade:_
Material o construction:_cast iron_40 PVC_ other(explain)
Distance rom private water supply well or suction line
Diamete
Comm ts: (condition of joints, venting, evidence of leakage,etc.)
SEPTIC TANK:_
(locate on site plan)
Depth below grade: 6 /
Material of construction: concrete_metal_Fiberglass _Polyethylene_other(explain)
If tank is metal, list age_ Is.age confirmed by Certificate of Compliance_ (Yes/No)
Dimensions:
Sludge depth: 3
Distance from top of sludge to bottom of outlet tee or baffle:1Y
Scum thickness: /'-.2 1 , )
Distance from top of scum to top of outlet tee or baffle:_ i
Distance from bottom of scum to bottom of outlet tee or baffle:
How dimensions were determined: -T,P
'omments:
(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.) ry
GREA TRAP:
(locate n site plan)
Depth be w grade:_
Material construction:_concrete_metal_Fiberglass _Polyethylene_otherlexplain)
Dimension
Scum thic ness:
Distance om top of scum to top of outlet tee or baffle:
Distance rom bottom of scum to bottom of outlet tee or baffle:
Date of st pumping:
Com ants:
(reco mendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
eviden a of leakage, etc.)
revised 9/2/98 Page 7of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
'roperty Address: 84 Emerald. Lane , Marstons Mills
Owner: Tim K in s k i
Date of Inspection: Ll-
TIG
HT OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection)
Iloc a on site plan)
Dept below grade:_
Mater I of construction:_concrete_metal_Fiberglass_Polyethylene_other(explain)
Dimen ions:
Capaci y: gallons
Design flow: gallons/day
Alarm resent
Alar level: Alarm in working order: Yes_ No_
Date f previous pumping:
Co ments:
(c dition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX._V
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal, evidence f olids carryover, evidence of leakage into or out of box, etc.) -
PUMP C AMBER:_
(locate o site plan)
Pumps i working order: (Yes or No)
Alarms n working order(Yes or No)
Com nts:
(not condition of pump chamber, condition of pumps and appurtenances, etc.)
revised 9/2/98 Page 8of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
lrop"Address: 84 Emerald. Lane , Marstons Mills
Owner: Tim K,ins k i
Date of Inspection: L.J—G _ _ /
SOIL ABSORPTION SYSTEM(SAS):✓
(locate on site plan, if possible; excavation not required, location may be approximated by non-intrusive methods)
If not located, explain:
Type:
leaching pits, number:_
leaching chambers,number:_
leaching galleries, number:_
leaching trenches, number, length::�L—
leaching fields, number, dimensions:
overflow cesspool, number:_
Alternative system:
Name of Technology:
Comments:
(note condition of spoil, signs of hydrauulic failure, level of ponding, damp soil, condition of vegetation, etc.)
CESS OLS:_
(locate o site plan)
Number an configuration:
Depth-top o liquid to inlet invert:
Depth of soli s layer:
)epth of scu layer:
Dimensions of cesspool:
Materials of c struction:
Indication of g oundwater:
inflo (cesspool must be pumped as part of inspection)
Comments:
(note conditi n of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:_
(locate on si a plan)
Materials of c nstruction: Dimensions:
Depth of soli
Comments:
(note conditi n of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
revise,d Page 9ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
''rop"Address: 84 Emerald. Lane Marstons Mills
lwner: Tim K ins k i
Jete of Inspection: 2)—(1 40-<>
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
U
1 -
a
revised 9/2/98 Page 10of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
roperty Address: 84 Emerald. Lane , Marstons Mills .
Owner: Tim K ins k i
Date of Inspection: Z,)—C ci, Q
NRCS Report name
Soil Type_
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep
SITE EXAM Slope
Surtace water
Check Cellar
Shallow wells
Estimated Depth to Groundwater f b Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observed Site(Abutting property, observation hole, basement sump etc.)
Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
_Checked pumping records
Checked local excavators, installers
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
revised 9/2/98 Page 11of11
TOWN)OF B/ARNSTABLE
LOCATION 7 /!l /ems f�TK §SWAGE #
/ -� ---
/ ASSESSOR'S MAP &
V''•,LAGE�� ---
INSTALLER'S NAME&PHONE
SEPTIC TANK CAPACITY _ b
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS—_
131TILDER OR
r
PERM:TDATE:•__7 l� COMPLIANCE DATE
Separation Distance Between'the:
` `7 Feet
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility
Private Water SLpply Well and Leaching Facility (If any well&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) yob�. Feet
Furnished by -
r
THE COMMONWEALTH OF MASSACHUSETTS
Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
0[pprication for �Digonl *pgtem Con5truction Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Locadress r Lot No. Owner's Name,Address and Tel.No.
� j A-,q-1v e
Assessor's Map/Parcel
S
Installer's Name,Address,and Tel.'N0. Designer's Name,Address and Tel.No.
o is l s'tr�
Type of Building:
Dwelling No.of Bedrooms 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
p
Nature of Re airs or Alterations(Answer when applicable) — X . X
Date last inspected:
Agreement:
The undersigned agrees to ens the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions f Title of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issue this oard of H t �-
Signed �' ` Date
Application Approved by Date r44—Zt-
Application Disapproved for theYollowiQ reasons
Permit No. J Date Issued a— L ( _- f 7
No.
THE COMMONWEALTH OF MASSACHUSETTS
Entered in computer:
Yes
PUBLIC HEALTH DIVISION -' TOWN OF BARNSTABLES MASSACHUSETTS
2pplication for Miq'ogar *p!5tem Construction Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) El Complete System O Individual Components
Locat dress r Lot No. Omer=s Name JA�ddres$,and Te'IJ 6..f
/17&r2A Id A,,I-,v�
eiAssessor's Map/Parcel '/S
Installer's Name,Address,and Tel.'No. Designer's Name,Address and Tel.No.
T 0''am' M 0 /L/?(.-�
`_aA P-N S-� b 1-C M�-
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other j Type of Building No.of Persons Showers( ) Cafeteria( )
Otheff ixtures
Design Row ~ ' gallons per day. Calculated daily flow gallons.
Plan Date' Number of sheets ! Revision Date
Title , t
Size`of Septic Tank Type of S.A.S.
Description of Soil f
d•
Nature of Re airs or Alterati s(Answer when applicable) /4� - b , X .2 / x �--,
Date last inspected:
Agreement:
The undersigned agrees to ense_tthhe construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions f Title 5Tf the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issue this Board of H a� _
Signed Date
Application Approved by Date t,Z-Z/ - 7
Application Disapproved for theYollowiny reasons
Permit No. 7- Z ?ice" Date Issued
-------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY, thAthe On-site Sewage Disposal System Constructed( )Repaired(''�pgraded( ) y x
Abandoned( )by �r !/G k
at 2 G /L•e l 1 has been constructed in accordance
with the provisions of Title 5 and the fbr Disposal System Construction Permit No. dated y' "' 7
Installer 7����S AfoA/ti Designer
The issuance of this permit shall not be construed as a guarantee that the system will functio as dels`igned.D / )
Date �✓- �� 97 Inspector_ t�� i'�- �(,d4
f
---------------------------------------- - -
No. ; g Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
Misposal 6pstem Construction Permit
j Permission is hereby granted to Construct( )Repair(�C Upgrade( )Abandon( ) r
System located at F,/►f 1�/ I /yr
IM
and as described i e 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 permit.
Date:
- Approved by
v
r✓ 4
NOTICE: This Form is to be used for the Repair of Failed
Septic Systems Only
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS)
hereby certify that the application for disposal works
construction permit signed by me dated /�— l _, concerning the
property located at ����� zy 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
Y There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
SIGNED : DATE:
LICENSED SEPT 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].
j xcrt
lie .
r f
r
TOWN OF BARNSTABLE
�Q SEWAGE # / 7-0 3
LOCATION
• / -- d
VIl,LAGE ASSESSOR'S MAP & LOT v A
INSTALLER'S NAME&PHONE,W:,. .... ----
/6 o b
SEPTIC TANK CAPACITY 3 2 k a G�
(size)
LEACHING FACILITY: (type)
NO,OF BEDROOMS_
' h
BUILDER OR.OWNER- ----
�/ COMPLIANCE DATE: 'y
PERM,TDATE:.--�/—�--�
Separation Distance Between the: 15/ Feet
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility
Private Water Supply Well and Leaching Facility (If any wells exist, /Z/U Feet
on site or within 200 feet of leaching facility)
Edge of Wetland and Leaching Facility(If any wetlands exist /t/0X/ Feet
within 300 feet of leaching facility)
Furnished by —
G
T3
.57
_ �
J1
L;O,CATLON SEWAGE PERMIT NO.
(� y I a T-:#4j?o.*;-a 114►,z 77 /,X3
YILLAGE
INSTALLER'S NAME & ADDRESS
!2
B U I,l D E R OR OWNER
We ` y 9pirp.1� 1eOz/3 /Z CORA
DATE PERMIT ISSUED �, _ � 7
DAT E COMPLIANCE ISSUED V6 ��
j s7
s�d?0
No............. 3.. FEE..... ....................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F H TH
........... Oti '�:......0F....... . ...... .. ................ ......------...---.._...........------
Appliratinn -fear Disposal Murks C oustrurtion Prrmit
Application is hereby'made for a Permit to Construct (�) or Repair ( ) an Individual Sewage Disposal
System at:
j'�Q h�" �'!a�►1 ........... J.Aj.L Ll........ ................................`�1` ......................................................
Location-Address or Lot No.
......... ------------------- ......JI.P X---?'322......R L&t L 1.-----------------._......----------
Owner Address
Installer Address
Q Type of Building a A,PE Size ----Sq. feet
V g— ................................Expansion Attic ( ) Garbage Grinder ( )N�
Dwelling No. of Bedrooms.............................. ..
aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures ------------------------------------------------------
W Design Flow-----------------'S7o-_____--.__---_-__--gallons per person per day. Total daily flow.........3.a.-Oz-----___-.__-__.-._-.._..gallons.
WSeptic Tank 4--Liquid capacityladtt-gallons Length______ _�_____- Width-.-__-r..._.. Diameter Deptli_ ---..._..
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No......1------------- Diameter........i.._..._... Depth below inlet.....G-_-..._._.__ Total leaching area._/A9.Q......sq. it.
Z Other Distribution box ( ) Dosing tank ( ) —0h_ I;Z- /,�-- 77
Percolation Test Results Performed by------- -- --------------------------------•............................. Date------------------------------------
a Test Pit No. 1---__________--minutes per inch Depth of Test Pit_.................. Depth to ground water...------_.--.--_---.__.
fXq Test Pit No. 2----------------minutes per inch Depth of Test Pit.--_-_----__.___.._- Depth to ground water-_.-.-_--__--.------....
.......... ... - -----------
Description of Soil " Da .. " �� ----------------P------- ----- -- ---------------------
cxj f Cam- — -( l��
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 Article 1I of the State Sanitary Code—The undersigned further agrees nct to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
gigned.. . • -•-----•...------•-•-------------------------------------- •--•-•-•--•---•--•......-----•--
_ Date
Application Approved BY -- ---------. . �l: ... 7.7
Date
Application Disapproved for the following reasons------------------------------------------------------------------------------------------- -------------------
------------•---------•-......••-•-••----------- ------------------------------------------------------------------------------------------------------------------------------------------------------
Date
PermitNo..........................................=--•••---•----- Issued........................................................
Date
No..............111. Flms......
.....................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD PF H TH
......OF....... _ : .e ............ ..................
Applirtttion -for Diipo-4ttf Works Tamitrurtion Prrtttit
Application is, hereby'made for a Permit to Construct (yam) or Repair ( ) an Individual Sewage Disposal
System at:
---------- ......... --•-•-----------
Location-Address or Lot No.
................... ....••• f} _!'i^I f f t-
_ Owner Address
W ......... ` f ---•-•-----•---------------------•-•............-----•........... .......................................1.A.6.t.r--••---------•---•----------------------.--
p Installer Address A i
d Type of Building e to.Pc- Size Lot..... . ';... . . ...Sq. feet
Dwelling—No. of Bedrooms----------$-------------------------------'Expansion Attic ( ) Garbage Grinder
aOther—Type of Building _-_----------------------_ No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures --•-------------------- ----- _-
W Design Flow..............•. 1�...__---------------gallons per person per day. Total daily flow......... _ ---_____--_-__.-.--__.gallons.
Septic T:Ink 4--Liquid capacity;_F 2agallons Length-------Cf __ '.4_._... Width_ __-- Diameter------- Deptli._� ._.......
Disposal Trench—No.-.-_--_--_-.---____ Width____________________ Total Length-------------- Total leaching area--------------------sq. ft.
Seepage Pit No....../............. Diameter-__--_-_�__`_-----.- Depth below inlet-----0.1.__.._... Total leaching area_..' a_2-__-_sq. ft.
Z Other Distribution box ( ) Dosing tank ( ) — Q . yt+ j*- 77
Percolation Test Results Performed by------ ------------- ----------------------------------------------------- Date--------------------------------------..
Test Pit No. 1----------------minutes per Inch Depth of lest Pit.................... Depth to ground water...----------.-__-_-----
Test Pit No. 2----------------minutes per inch Depth of Test Pit.-__--_---____._-- Depth to ground water-------------------
------------------- ,-1 ---
D Description of Soil- _-- - --�7� :-- -- --------- --- --- _ _ ��
k' ' �� Isar
x ------------
W
UNature of Repairs or Alterations—Answer when applicable.-.--------------------------------------------------------------------------------------------.
-----••--------------------------------------- -----------------------------------••---••--•---•-------•-----•------------------------I----------------------••--- -----
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate;of Compliance has been issued by the board of health.
ned__ k ss----------------------------------------------------------- T
Date
Application Approved B
PP PP Y yr` 6I�Lr ,f I 7
Date
Application Disapproved for the following reasons:--------------------------------------------------------------------------------------------------------•-------
..........`:.--•-•--•----•---....--•---•-----•---.....--•---•-------•--...-----•-------•----•----•----•------_-.---•-------------------•-----•--------------------------.._-----------------------•-•---
i
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......1_4!7.2*1:'z...........OF....... ..............................................
Trrttf irtttle of Tlintpttttttrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (Vo S or Repaired ( )
bY-------•----•--_---w '-. v-4_-AI.............................................--.....................................................................
Installer
at ------------------: ... . ........................................-•-------•-------
has been installed in accordance with the provisions of :A cl XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit N ._7r___.__t_ __ ______________ dated_..._...'l,"'--------------------------------
.
THE ISSUANCE OF THIS CERTIFICATE SHALL, NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUN TION SATISFACTORY.
DATE.......................... - ...... ;2.,C>----------lc�-�..------. Inspector---- ...-••--•... ...........................................
THE COMMONWEALTH OF MASSACHU
BOARD C EALTH
.......... �. �. ...OF.... ........ . .......r...........................•-----------. ..
No......................... FEE----
... �i��tt�ttl �rk,� ��tt�trttrti>ait �rrtttit
Permission is hereby granted---------A._..._ .. . .........
to Construct ( ✓) or Repair ( ) an Individual Sewage Disposal System
at No-------jI-J-A-------a__m.j .. u !�fI = -...,..
street
as shown on the application for Disposal Works Construction�P_ No Dated...."._ _ . 77
...--•--• .............................
DATE........ ............ ................................... Board of Healt
LLL���//////
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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