HomeMy WebLinkAbout0040 FAIR ACRES DRIVE - Health 40 Fair Acres'Drive ._ .
-� — �- Marstons Mills P x
124 054
I
No. m J —0q Fee d `'
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE,MASSACHUSETTS
N" ftpliratton for ;Dvgpoal bpztem (Con0ruction permit
Application for a Permit to Construct( _ )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. F&6 T f Ow`'s Name,Ad d Tel.No. \
Assessor's Map/Parcel ^ Q 5 � � D�j
Installer's Name,Address and Tel No. Designer's Name,Address and Tel.No.
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 7`�d gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date `T'1"77
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of epai or Alterations(Answer when applicable)
. —e�ai�r�GL
Date last inspected: — Z—o 7
Agreement:
The undersigned agrees to ensure the construction d maintenance of the afore described on-site sewage disposal system
in accordance with.the pr ' e 5 of the E it nme ode and not to place the system in operation until a Certifi-
cate of Compliance has been' this o d o alth.
Signe Date ' 4 ,Q 5"—
Application Approved by Date g �
Application Disapproved for the following reasons
i
Permit No. �� 5 ^o�'L( Date Issued 3 O
No. � Fee L O�
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC'HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Yes
2pplication for Otopozal Opotem. Conotructiori Permit
Y.Application for a Permit to Constrict( )Repair( )Upgrade( )Abandon( ) ❑Complete System El Individual Components
Location Address or Lot No. do ��r �c,Q Owner's e�4dd�d Tel.No. r✓1 kF i �#
Assessor's Map/Parcel O s L
r
5�0 > �2e s 1D2c-u-c
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
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 7 - /- 7 7 '
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
/t
=Nature of epai or Alterations(Answer when applicable)
Z
Date last inspected: 4 — Z
Agreement: „
,._ The undersigned agrees to ensure the construction nd maintenance of the afore described on-site sewage disposal system
`in accordance with,the provisions-of Title 5 of the E vir nmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been,iss edsby this"Board of'H alth.
Signe v Date " /, 6
Application Approved by Date jb 5
' Application Disapproved for the following reasons
a
" Permit No. ra-Cc 5 —0'1 4A Date Issued 3 g 5
r
THE COMMONWEALTH OF MASSACHUSETTS
C BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS-IS,TO CERTIFY, that the On-site Sewage Disposal System Constructed ( )Repaired (K)Upgraded( )
Abandoned( )by`�Q' -&,
at i cIr-,o has been constructed in accordance
with the'Provisions of Title 5 and the for-Disposal System Construction Permit No. rQ(f)5 -0744 dated 3) ) O S 1��
Installer � Designer
The issuance of this ermit shall not be construed'as a guarantee that the system will function as designed.
Date Z;), Trsgect^- �1�'_"�--�—�
�J���—` ---®®--------------------
No. QW Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
�Q \�CP"- 30iopozal 6pgtem Cott.5truction Permit
Permission is hereby granted to Construct( )Repair)-Upgrade( )Abandon( )
System located at e�C) yy�
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions. ."
Provided: Const ctio must be completed within three years of the datehis permit.
Date: N ro'f t
J 970 5 Approve by_
}
COMMONWEALTH OF MASSACHUSETTS
' EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION-
RECEIVED
S F P 15 2004
TOWN OF BARNSTABLE
TITLE 5 HEALTH DEPT.
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION '
Property Address: Al QC
Owner's Name:— 4*aliie. 4,615 r'►.nl ;AP
Owner's Address: -ARCEI.,
Date of Inspection: --rq G/ Off' -
Name of Inspector: (please print)D6uglas A_Brown
Company Name: Douglas O n Septic Inspections
Mailing Address: RO Rev 14G
GentervilieTelephone Number: R 02632
CERTIFICATION STATEME�a
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 the inspection. The inspection was performed based on my
training and experience in the proper function and intenance of on site sewage disposal systems.I am a DEP
approved system inspector pursuant to Se n 15.340 of Title 5(310 CMR 15.000). The system:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: [�y
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection.If the system 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
DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving
authority.
Notes and Comments
` s{moo kc u�c h T !fie \c .�v Lc� i� _c��;s - rS, 15 nn �oe;� dose
f RE �Qs�sC� \�► e�C y� r �G"s Ae,' ECPC1 tN = �� �.x�T�Oe`r� CST �fl P\A" Cj J�V
u000-e� Co-- i7 JetaC� �dT}L�kr\ O t�1�
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
fir6r-el
,` Title 5 Inspection Form 6/15/2600 page 1 ��v si�� �� /Cl31/2av
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION N FORM
PART A
CERTIFICATION(continued)
Property Address: 1I0 Fir -r-_�1-M Vi(
Owner's Name: �vrF�� I.cydso'�
Owner's Address%
Date of Inspection: -p Lj
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System asses:
I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CUR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments: _ 11
AAt►, , PASCSC C� 1
fl) j kA
B. System Conditionally Passes:
one or more system components as described in the"Conditional Pass"section need to be replaced or
repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the following statements.If"not determined"please explain.
The septic tank is metal and over 20 years old' or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
Page 3 of l l
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: Hd -Fr�;r , rff C tjtgp
iLlc�rs N(A k
Owner's Name: _f. o.iHs
Owner's Address: gzzaQNGe
Date of Inspection:g3-4L„r!)!A
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 public health,safety or 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 public health,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 any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ the system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
_ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
_ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well".Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory,for 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,provided that no other
failure criteria are triggered.A copy of the analysis must be attached to this form
3. Other:
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 4G' .r/ Py
4Aw js1
Owner's Name:_ C J 1 tic,10L600
Owner's Address: -
Date of Inspection: -a -oct
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for AL inspections:
Yes No
ackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
-- Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool .
t/tiquid depth in cesspool is less than 6"below invert or available volume is less than%2 day flow
_ _✓l�cquired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
✓Any portion of the SAS,cesspool or privy is below high ground water elevation
Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
_any portion of a cesspool or privy is within a Zone 1 of a public well.
*- Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DER certified laboratory,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,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
-4- (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either`des"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
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
I
— — 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
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes".in Section D above the large system has failed.The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system i.n accordance with 310 CMR
'. Page 5 of I I
OFFICIAL INSPECTION.FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: '-Q •r, -{
-AA A
Owner: f u/'61 4&1-50--J
Date of Inspection: (o 5 ti 2—o- 1/
Check if the following have been done.You must indicate`yes"or"no"as to each of the following:
Yes No
Pumping information was provided by the owner,occupant,or Board of Health
I�Were any of the system components pumped out in the previous two weeks?
Has the system received normal flows in the previous two week period?
�Have large volumes of water been introduced to the system recently or as part of this inspection?
Were as built plans of the system obtained and examined?(If they were not available note as N/A)
Was the facility or dwelling inspected for signs of sewage back up?
✓_ Was the site inspected for signs of break out?
,f 1��uC�w
— _ Were all system components,..;=the SAS,located on site?
f— Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees, material of construction, dimensions,depth of liquid,depth of sludge and depth of scum?
_ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has been determined based on:
Yes pcj
Existing information.For.example,a plan at the Board of Health.
Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)[310 CMR 15.302(3 b)]
5
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
Owner's Name:
Owner's Address:
Date of Inspection: �o
RESIDENTIAL FLOW CONDITIONS
Number of bedrooms(design): '�L Number of bedrooms(actual): '3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
—
Number of current residents: -
Does residence have a garbage grinder kD
(yes or no):
Is laundry on a separate sewage system(yes or no): !;[if yes separate inspection required)
Laundry system inspected(yes or no): psi k
Seasonal use:(yes or no): AAC2
Water meter readings,if available(last 2 years usage(gpd)):
Sump Pump(yes or no): AV()
Last date of occupancy:L{t N F
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow(based on 310 CMR 15.203):
Basis of design flow(seats/persons/sgft etc.): r
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/use:
OTHER(describe):
Pumping GENERAL INFORMATION
P� g Records
Source of information:
Was system pumped as part of the inspection(yes or no):
If yes,volume pumped:_gallons--How was quantity pumped determined?
Reason for pumping:
TYP�OF SYSTEM
Septic tank,distribution box, soil absorption system
_Single cesspool
_Overflow cesspool
�vY
Shared system(yes or no)(if yes,attach previous inspection records,if any)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tim tank _Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
0 N)
Were sewage odors detected when arriving at the site(yes or no): J�
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C .
SYSTEM INFORMATION(continued)
Property Address% qb 7i frr
Owner's Name: jfjj14,7i5 LaSc§to
Owner's Address:
Date of Inspection:
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction:_cast iron _40 PVC_other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK:_(locate on site plan)
)
Depth below grade:_11 �
Material of construction:_c'�ancrete_metal fiberglass_polyethylene
other(explain) i
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions: 1000 c,ck
Sludge depth: W 11�—
Distance from top of sludge to bottom of outlet tee or baffle: —'G, r�
Scum thickness: +f
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
How were dimensions determined:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
GREASE TRAP:_(locate on site plan)
Depth below grade:-
Material of construction:_concrete_metal fiberglass_polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping: .
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
• Page 8 of 11
OFFIC
IAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: f I
/lAc�d S tthgl 9 �a�
Owner's Name:
Owner's Address:
Date of Inspection: !jP; t j
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass_polyethylene other(explain):
Dimensions:
Capacity: �alions
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):_
B f 1t3 C ff Ve
PUMP CHAMBER:_—(locate on site Ian)
Pumps in working order(yes or no)':
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
Page 9 of l l
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
_ SYSTEM INFORMATION(continued)
Property Address: it 0l-���3 Ar g CS-qQ i),p
Owner's Name: y
Owner's Address:
Date of Inspection: °- -0
SOIL ABSORPTION SYSTEM(SAS):_(locate on site plan,excavation not required)
If SAS not located explain why:
Type,
t/leaching pits,number: `1--
leaching chambers,number.
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Typetname of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.): .
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
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.):
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT.FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
M6�C < AA et
Owner's Name:
Owner's Address:
Date of Inspection: ,
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference Ian ks or
benchmarks.Locate aL wells within 100 feet.Locate where public water supply enters the building.
3
A- S.3 e i3.2- :2-C
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r Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEMM INFORM[AILION(continued)
Property Address: q0v.e
Owner's Name:
Owner's Address:
Date of Inspection:
STTE EXAM
Slope%
Surface water%
Check cellar:
Shallow wells
Estimated depth to ground water c/ feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
14,vD c,,sS t' Ica :.a�N i e f et brNoc's
Tn \ THE,COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CE TIFY, that the On-site.Sewage Disposal System Constructed ( )Repaired(�)Upgraded_( )Abandoned( )by "� _
at
with the provisions of Ti 1e 5 and the for Disposal System Construction Permit No. has been constructed in ac -
with
Installer `s " dated L _5
Designer
The issuance of thisTerTit shall not be'construed as a guarantee that the Ksl�e �n�as�es�igned.
Date_. `/► �� Inspector
TOWN OF BARNSTABI
c
'LOCATION �'i� -�''® ��' J SEWAGE #'
VILLAGE ,ASSESSOR'S MAP& LOT
INSTALLER'S NAME&PHONE NO.
I SEPTIC TANK CAPACITY
LEACHING FACILrN: (type) ,
- i (size)
NO,OF BEDROOMS
BUILDER OR OWNER 4 . 17
PERMIT DATE; I 0 COMPLIANCE DA
Separation Distance Between the: �- s -—
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water,Supply Well and Leaching Facility (If any wells exist
on°site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished.by
f
i
I
ay os
µ
f
X-Y
�LO CATION SEWAGE PERMIT NO.
7 ',O
VILLAGE
/11-1,42 5 To/v
INSTA LLER'S NAME i ADDRESS
Xe:W.c , GQIyS7ro. >uc 32 WiANNoAv6 oST
BUILDER OR OWNER
chajec,-s �C q�csay
DATE PERMIT ISSUED /��3A75
DAT E COMPLIANCE ISSUED
AA
Ilk
W �
i r
I �,
No................'.-D--- Ilt Fw3............... ...........
THE COMMOIV!WE^...LTH OF MASSACHUSETTS
BOAR® OF HEALTH
-----/..t�..v1�.Cv---------------0F.... 1!S7- ,.) '�.�. ................................
Appliration for Diivoaal Workii Tontitnution ramit
Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal
System at:
........... r ... .............................................. I._1 ,.�1�............................ ..........•...•...•......_............-_.
.....
Location-Add re or Lot No.
r Owner Address
a :... ...................... ......................
Installer Address ��//
Type of Building Size Lot_.7_Q_ d'�......Sq. feet
Dwelling No. of Bedrooms............�...........................Expansion Attic ( ) Garbage Grinder (V-)
Other—Type of Building No. of persons............................ Showers — Cafeteria
Q' Other fixtures .____.
w Design Flow........ _ _...... per person per day. Total daily,flow--._._. 0..................... lons.
WSeptic Tank—Liquid capacity,/5020gallons Length/Qtt.e"... Width.+.`-�5..�._ Diameter__5-'s--�--__ Depth.. .. °i
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area............. __._sq. ft.
3 Seepage Pit No._..e.�-_ _____.. Diameter........ Depth below inlet_= _ ....... Total leaching area.. 3.....sq. ft.
Z Other Distribution box Dosing tank ( )
'-' Percolation Test Results Performed by... - 1.- .':d.? _/ .Date ..____�_.._.._...._
_a Test Pit No. 1....4n _._minutes per inch Depth of Test Pit.....!° '.___... Depth to ground water✓✓io P.`�t.'..__.
(i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Description of `" I �(......3.6- 7 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 TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Sig d
ate p
Application Approved BY �� u! ... '----•-•----------•-- � -.................7.7
Date
Application Disapproved for the following reasons:'---'-'•••-....................................................................................................
.............................•---•-------•--------••----------------------....--------•---•-----------•---'-"-'-""-"-"'----'-'-----'--'----'-'-------•---•---•---•---•---'--•--------••---"''''•"
Date
PermitNo......................................................... Issued...../1.-°Z-7 ............................
Date
No..... ............ Fps. 41
........................._
' THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.. >'! ................OF....
Appliration for Uispvii al Works Tontrnrtion Prrutit
Application is hereby made for a Permit to Construct (y) or Repair ( ) an Individual Sewage Disposal
System at: f __
.......
....
- »` ............:!•...... =�-�a •f......
----------------------• -...............1 .....--•�....-.. . � ............. -•----------•--•--------.
_Location-Address or Lot No.
: �... l �l �T ......,?C....• ............................................................_-----------------------
....--•--
..:.. - .............
Owner Address
a ... . •.......................................................... ...........................:.....................................................................
Installer Address „� /
Type of Building ,/ Size Lot...'=.... ...... ......Sq. feet
v Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder (�')
'04 4 Other—T e of Building No. of persons............................ Showers — Cafeteria
Other fixtures .. -------------
-------------
Design Flow........ ....,,,5.5_.....gallons per person per day. Total daily flow......... gallons.
WSeptic Tank—Liquid capacity/.5.�Ogallons Lengthy__"... Width._�.e.`.._ Diameter_ -- Depth:4%<."
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area_____..-------.,-----sq. ft.
Seepage Pit No...J.,1__?........ Diameter....... ..._..._. Depth below inlet.::]_:S........ Total leaching area.3.'if....sq. ft.
Z Other Distribution box (vl) Dosing tank ( )
Percolation Test Results Performed by._._'.'�}. _: '¢ _,./^" , !'' !J`,�.Date// _ ..........................
aTest Pit No. I___4:_2_._.minutes per inch Depth of Test Pit __I_-._.�._._.._. Depth to ground water�'•_.......i2 5
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P1 ..........I... --------•--------------------------•--•--•-•------..........----•------•.-•-•- ...................................... --•--..........•.
O Description of Soil.�_'. ?r..../ � ,. ' S is 4n!L ''� - �' r' ,t,�9 r� i ✓7� r �- 1F,+ +<n.,
,r•��v ................. -•-•-----••--•----------•------
................................+!-r�_'. ,r_ ?'m'i ,r�.I'• f/ _ _ -Y.- S .............................t /�
U 7' J ..... ............. ...........................
................................................•...._.._._.__.......................__._............._.........__.............._................_......__............_.............._..._...._.........
U Nature of Repairs or Alterations—Answer when applicable...._........................................................................................._..
----------------------------------------------------•-•----•------------------.........•--•••-•---•----------•--------------•.....-••-•-------------------•--•--•---------•---.......----•--•----
Agreement:
The undersigned agrees to install thet aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT TIE 5 of the State Sanitary;Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
..----------•......
�y
--- to
A C/•` �O '►
a �j
Application Approved,B. ....................................................... .....__..._... --•---------------.... --- ----------
ate
Application Disapproved for the following reasons---------------------------------•-----------•---------------------------------------------------------•---.---•-
...............................•----------------------------....-•----...-•---• ----•-----•------------------•---------••-------------------......------------------......---------------------......--
Permit No...................... '.: Issued......
f 7
Date
Date -----------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
J ...............OF....... ^tS". ! .x......................
Trrtifirate of Tontplianrr
THIS4,14sople
FY, That the Individual Sewage Disposal System constructed""(- ) or Repaired ( )
----- q'. off
at.............-............................................................
)"'rr• 1 ------..... •-•--•-------
has been installed in accordance with the provision 7W I T4Z2,05 of The State Sanitar Coe as described in the
application for Disposal Works Construction Permit- o......................................... da.tw��� ` -9r
---
THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED A A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
2n
DATE �r-2_ Z �N,� ..... . a'Inspeetor
I
i.y..t.. � e« S 4'ni 7.i
'- �v.�'..._ ��S 1�a� eF"ti`a'...M-�fA't•^" kSS� 'DMty e'"�N,�,
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
_.1�.. �✓"l r� OF.... .Lo ................. v�
No........................ _ Td.." ..........
Elispo,ittl
n#rnrion rni�
P . m onis hereby granted--- ...... ---- •-- ................------------------------------------••-•-•-•-•-----.............................
t f iiu S ��f11&Ghk 7sal t� �
� �o............................................................... � - -- - � .. •--• -- -- - ....•-- � ..
11f.............................
.Street
as shown on the application for Disposal Works Constru '�i P N ...............................
Date���`�.�...'...................
�z
��,.. • Board of ealth
DATE---•-- ----------------•---- .................................................
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS - as
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