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HomeMy WebLinkAbout0257 MISTIC DRIVE - Health 257 MISTIC DRIVE,MARSTONS MILLS A= 080 017 TOWN OF BARNSTABLE L)CifiION­451 ISTi C., Qr ly(5 SEWAGE# �Ot. VILLAf=F �To�.M� ASSESSOR'S MAP&PARCEL l�pf QJ INSTALLER'S NAME&PHONE NO. NE 1Ct� �ta Lq SEPTIC TANK CAPACITY �T�C�S'i-11� LEACHING FACILITY: a - size _ NO.OF BEDROOMS OWNER -)-rd►Jk, l3 hr► e_Y l0 PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If-any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY t (��q(� oG HwS� ��. �6� 1 �.I� i�- p.�,. � .. d�0'���' r���� �Z�� s�'r I� _ No..ram"" Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ZIppYication for �Digogal *- wemc Con! truction Permit Application for a Permit to Construct(� Re air(yrUpgr ade( ) Abandon( ) ❑ Complete System ❑Indrvidual Components Location Address or Lot No.)-5-7 mNcmi C w O ner's Name,Address,and Tel.No. HA(Lc,`l--eJ Mli. S Assessor's Ma /Parcel C ZS'11�yS11Cn� p ® 0 a 1 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. QP�•��TN Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building � ,d, � o,�.-,y No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil i Nature of Repairs or Alterations(Answer when applicable)RA1% 1144E Mfti►a brile L4CE,R.I06 i-At-3 z'VZ) W M&jC- jj3� ut-ii . i OStp►t,.t- A 1W 6N—L +v Ak4f Ck44 swit 19 TV-C SIc^PflL'iku•K-wl N tANMS`` o Oj.4tP 1-U �ut✓IP 'Mc <O%got uP -to 6aAN,iT`I FLop Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board Health. Signe Date Application Approved by Date Application Disapproved by: Date for the following reasons Permit No. C7` ~j Date Issued"7i Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Zlp�lication for Migpogal &pgtem Congtruction Permit Application for a Permit to Construct(.6. Repair(A41""Upgrade O Abandon O ❑Complete System ❑Individual Components Location Address or Lot No.257 mNc,-t1 c c 12 Owner's Name,Address,and Tel.No. q"(►'1(Ls M I L S 2E1NvL(Wo vL.t U Assessor's Map/Parcel O b O 1 �S1 A&_��M, Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. �700— I11A(LTNN Type of Building: Dwelling No.of Bedrooms -7 Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures ... Design Flow(min.required) F gpd Design flow provided ',_ gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil t Nature of Repairs or Alterations(Answer when applicable) P-A\S- T1-4(- MA'rJ U NC ( -24�It�1aN�C 17D %:(t mZ,&C Tf 4c CLSo'Z. C U+; . 1 t,J`_>PP LL A '413 t-,,A�,L C-J (VAP (1-tAm R6-A TK 5L;-r-(NC T'Kt� t,-)P, M 1"s"Ac) (7wA p 1-u 1 Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board o Health. Signed— Date - = - - Application Approved'by Date Application Disapproved by: t Date . ` for the following reasons - C Permit No. tr� Date Issued THE COMMONWEALTH OF MASSACHUSETTS , - BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired (V< Upgraded ( ) Abandoned( )by / /' �.. � at 2 _1- T �!T f 12 1-. has been constructed in accordance J with the provisions of Title 5 and the for Disposal System Construction Permit No. A6 f, - —/4 dated O!� . Installer/- �i � Designer / #bedrooms Approved design flow � gpd The issuance of this permit shall not be construed as a guarantee that the system will fun is onn as desi�gned. Date �1 Inspector 1 J ——————— v———, I————————————————————————————/ —————— / NO. � ✓' CJ Fee 0 t) THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS *igo!6 *pgtemt Congtruction Permit Permission is hereby granted to Construct ( ) Repair ( ✓f Upgrade ( ) Abandon ( ) System located at �57 S '�7 r-A,i- and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title S and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of�this permit. Date .151�/ Approved�b_y_ 1 �"�pNG l S t5l4t.�a � ` A 6 r ► � y a© i c 50 y , S7 FT i e 1 /� �.� /d �Gait' �✓��s � � ,�1��:r�/�'''c''�,�d.�'�ri'�`�� '/r,�i.�� '.�" �/'.� 4 1 h f �� t y,. CERTIFIED SEPTIC SYSTEM LIEUT. LOCATION 257 MISTIC DR. MARSTONS MILLS , MA MAP 080 PARCEL 017 LOT 42 PREPARED FOR SELLER MR . DONALD F . ROYCROFT 257 MIS TIC DR MARSTONS MILLS , MA BUYER MR. & MRS . FRANK BARBARIO 62 MUSKET LANE MASHPEE , MA 02649 PREPARED BY HILLIARD HILLER, JR. 41 MAPLE AVE CENTERVILLE , MA 02601 508-778-1472 7. '1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR M Address of property aS7 Owner ' s name /`-vim Date of Inspection P, ig-7S- S_A;y5_ PART A CHECKLIST Check if the following have been done: ri Pumping information was requested of the owner, occupant, and Board of Health . t/ None of the system components have been pumped for at least two weeks and the system has been receiving .normal flow rates during ,that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. ri 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. ci The site was inspected for signs of breakout. A11. system components, excluding the SAS , have been located on the site. r/ 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 SAS on the site has been determined based on existing information or approximated by non-intrusive methods. The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of SSDS. a�. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION FLOW CONDITIONS If residential number of bedrooms number of current residents garbage grinder, yes or no laundry connected to system, yes or no seasonal use, yes or no If nonresidential, calculated flow: i593 - So�' cqc Water meter readings, if available: i5sa - Pi(��%;;Lf,tslt Y Last date of occupancy GENERAL INFORMATION Pumping records and source of information: 1iz System pumped as part of inspection, yes or no if yes, volume pumped / Gff 4, Reason for pumping: iD " G�vl� G�/r9t' .SUL/G G✓/7i/ SUG�%(�5 `.Type of system Septic tank/distribution box/soil absorption system C� sYsTi-,•,s, Single cesspool _ overflow cesspool . Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Other (explain) Approximate age of all components. Date installed, if known. Source of information: _Sys Tf,-? //i/5 Sewage odors detected when arriving at the site, yes or no t -'57 MISTIC DR MARSTONS MILLS THIS SYSTEM HAS TWO PARTS . SYSTEM A IS OLDER AND CONSIST OF A SEPTIC TANK, A "D" BOX. AND A LEACHING PIT . SYSTEM B IS NEWER AND HAS ONLY A SEPTIC TANK AND A LEACHING PIT . THE TWO SYSTEMS ARE CONNECTED BY A PIPE UNDER THE BASEMENT SLAB WHICH ALLOWS FOR OVERFLOWS FROM SYSTEM A TO SYSTEM B . WATER FROM THE KITCHEN FLOWS INTO SYSTEM A AND DOES NOT FLOW TO SYSTEM B UNDER NORMAL CONDITIONS . I WAS TOLD BY THE OWNER THAT IF THERE IS A BACK-UP IN SYSTEM A THE CONNECTING PIPE IS CONSTRUCTED SO THAT THE OVERFLOW IS DIRECTED TO SYSTEM B . SYSTEM B ALSO .HANDLES A BATHROOM AT THE OTHER END OF THE HOUSE . asp 47 � I / 1 i 1 i 6 5%5 C3 1 - 1 I SysrE.� fI , 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SEPTIC TANK: SYSTE�r r9 ( locate on site plan) depth below grade: //rrT /,vGcT El-o 3 ' /7T DvTG� r E,v� material of construction: ��concrete metal FRP other(explain) dimensions: y'io ("oQ) 1G�� sludge depth /G" distance from top of sludge to bottom of outlet tee or baffle scum thickness distance from top of scum to top of outlet tee or baffle IY4 distance from bottom of scum to bottom of outlet tee or baffle Comments : ( recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, recommendations for repairs, etc. ) Gow, SAe j,�/�7CL f/t S Gi9•Ca. �P£c v.•r.�i,� �.v/, ct/iJ�G�,t� Th'/S S,v<TE,'! /S .__fl....1j�G�_. _,�11__Z�/�. T/Yr 'd �3oX �;va o�TC �L T /z'•�a �/= Ti�� DISTRIBUTION BOX: c/ SYST,t," /a ( locate on site plan) O depth of liquid level above outlet invert Comments : (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, recommendation for repairs, etc. ) 40.....-491X--�czv (cif !Li�_� � PUMP CHAMBER: ( locate on site plan) pumps in working order, yes or no Comments: (note condition of pump chamber, condition of pumps and appurtenances, recommendations for maintenance or repairs, etc. ) 10 t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SOIL ABSORPTION SYSTEM (SAS) : r/ �y�5%�i�r A ) (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: 1'Ype leaching pits and number leaching chambers and number leaching galleries and number leaching trenches, number, length leaching fields, number, dimensions overflow cesspool , number Comments: (note condition of soil , signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs, etc. ) L CESSPOOLS (Locate on site plan) : number and configuration depth-top of liquid to inlet invert depth of solids layer depth of scum layer dimensions of cesspool _ m1atel'i;.11.s of construction indication of groundwater inflow (cesspool must be pumped as pert of inspection) Comments : : (note condition of soil , signs of hydraulic failure, level of ponding., condition of vegetation, recommendations for maintenance or repairs,etc. ) PRIVY : ( locate on site plan) m.iterials of construction dimensions depth of solids Comments: ( nuLe condition of soil , signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs, etc. ) 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D SYSTEM INFORMATION continued SEPTIC TANK: 5%S7-,rr, ( locate on site plan) depth below grade: I r material of construction: _Z concrete metal FRP other(explain) dimensions:_ J— sludge depth _,?&/ "distance from top of sludge to bottom of outlet tee or baffle _o 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 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, rccommenclatlons for repairs, etc. ) -- 71jx A Lz--V-A-h,j rCZ- /L' 71le —_k vl-�Y TLu9 �/c'i�.� r! L � 12h' - r>.4�,�'.�-v ✓f /��s,L'it ol//'mot Th`� exs/r r DISTRIBUTION BOX: ( locate on site plan) depth of liquid level above outlet invert Comments: (mote if level and distribution is equal , evidence of solids carryover, evidence of leakage into or out of box, recommendation for repairs, etc. ) PUMP CHAMBER: ( .l ocate. on site plan) pumps in working order, yes or no Comments: ( note condition of pump chamber, condition of pumps and appurtenances, recommendations for maintenance or repairs,etc. ) 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SOIL ABSORPTION SYSTEM (SAS) : ! % /7 .Q (Locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type leaching pits and number / G leaching chambers and number leaching galleries and number leaching trenches, number, length -1each:ing fields, number, dimensions overflow cesspool , number.. Comments: (note condition of soil , signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs, etc. ) CESSPOOLS (locate on site plan) : number and configuration depth-top of liquid to inlet invert depth of solids layer depth of scum layer dimensions of cesspool materials of construction indication of groundwater inflow (cesspool must be pumped as part of inspection) Comments: ( note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,etc. ) PPJVY : ( 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, recommendations for maintenance or repairs, etc. ) 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100 ' j M u y, �• s vs%E.5 � 74:5 s DEPTH TO GROUNDWATER S ,, C G depth to groundwater �o C method of determination or approximation: _��vo �Gh-✓/91��•�/ /�,t-/? /3/�%yr/fl/�L�C G/S /S 70' O�i�l/�' G� /�>T' /S __�'l " (�iXiy,�4��'Ti•i� TL.►✓/'�%.sir/ �E�� �3/�,-���l�,s G.G "O,3sC�d,F� cyAT.�ic i /S 5'3 �. vscs 12 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C FAILURE CRITERIA Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of determination in ill instances. If "not determined" , explain why not) Backup of sewage into facility? 41 Discharge or ponding of effluent to the surface of the ground or surface waters? Static liquid level in the distribution box above outlet invert? NA Liquid depth in cesspool <6" below invert or available volume< 1/2 day flow? _ V Required pumping 4 times or more in the last year? number of times pumped Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? Is any portion of: the SAS, cesspool or privy: below the high groundwater elevation? �l within 50 feet of a surface water? wi.thin. 100 feet of a surface water supply or tributary to a surface water supply _ Al within a Zone I of a public well? Al within 50 feet of a bordering vegetated wetland or salt marsh (cesspools and privies only, not the SAS) ? within 50 feet of a private water supply well? _ Al I.ess 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 analysi for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. 13 SUDSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D CERTIFICATION s S"7 /1j/S i'/C %,i. /117-1Z Name of Inspector Company Name Company Address Oo /3�x Certification Statement I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true, accurate and complete as of the time of inspection. The inspection was performed and any recommendations regarding upgrade, maintenance and repair are consistent with my training and experience in the proper function and manitenance of on-site sewage disposal systems. r Check one: 11i1Ve not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15. 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. 1 have determined that the system fails to protect public health and the environment as defined in 310 CMR 15. 303 . The basis for this determination is provided in the FAILURE CRITERIA section of this form. Inspector ' s Signature : p � e Original to system owner _Copies to: Buyer ( if applicable) Approving authority LOCATION , S`EINAGE PERMIT N0. c VILLAGE INSTA LLER'S NAME & ADDRESS R_U.ILDER 0It OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED G _ 6 it KEY NUMBER <6605 > NAME <ROYCROFT, DONALD F > B-C 1 B-C 2 B-C 3 B-C 4 STREET 257 MISTIC DR CTTY MARSTONS MILLS ST MA ZIP 02648-1409 REF 1 REF 2 PHONE ( ) - REF 3 REF 4 METER NO. < 6128> DATE READING CONS STREET <MISTIC DR NO. 257> 12/31/94 3 38 CITY MM H L42 ST LOC 11/08/94 0 0 PHONE ( 508 ) 428-4683 11/08/94 -7-9-1- � 06/30/94 756 1 ROUTE NUMBER 06 12/31/93 744 38 SERVICE DATE 10 20 80 06/30/93 706 12> METER DATE 11/08/94 12/31/92 694 44 CAPACITY 7 06/30/92 650 11� STYLE T10 SIZE 1 RATE SCHEDULE KEY PIT PLASTIC NOTE RR ON FRONT ADDITIONAL CONS 0 ALTERNATE MIN 0 TOWN OF BARNSTABLE LOCATION 96 7 !,71<src ,!2e SEWAGE # VILLAGE/0 ,s/�,y�, ASSESSOR'S MAP & LOT �0/7 lnVaP�'c.Tves NAME & PHONE NO. h! if/G 22,? SEPTIC TANK CAPACITY oR T/>.yf,5 LEACHING FACILITY:(type) a A/Ts (size) 6' 44 pv,B�/c NO. OF BEDROOMS _PRIVATE WELL OR PUBLIC WATER wAT OR OWNER ^ye, DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No as7 , �isTiG p�ivr_= ,� m . ���a'' J'y" O ��� f � / �/� � L r� I '�" �- s- � �%S��yi� 3��® fi-z w L O-C AT ION 3 SEWAGE PERMIT NO. c 6/ VIL~LAGS M/9R Sro)v(S INSTA LLER'S NAME i ADDRESS !!ALDER OR _--OWNER DATE PERMIT ISSUED DAT E C0MPLIAN,CE ISSUED OP. c� m -,&r, D •� f'`-PI ` ,r No....... .. ::r 7 .�>�..� d................. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH -------1.0LOO..............-----0......:......A26k Lc..-----.---------................... Appliraa#iota for Diipoiiaal Vorkti Tomitrur#iort Prrutit Application is hereby made for a Permit to Construct (L,1 or Repair ( ) an Individual Sewage Disposal System at ................--...._.... .......... ................-•-•-•--............................ -•-............ ---- Location-Addres ------• -- - ---.•.----o: Lot No. ---------------------- Qt ds c-� l�.CP1 .. --•----------------------------------••----•---.... Owne Address -------------------------------4014 ---- ..... .r�--i .................. ................... ---------------------...--------------...--- Installer Address d Type of Building Size Lot.__._ $_ ...Sq. feet V Dwelling—, No. of Bedrooms........._.S------------------------------Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................. No. of persons---•-__-•___-____-__.______- Showers ( ) — Cafeteria ( ) dOther fixtures -------•------•-•-••--•---•--- --- ---..... --•- ------ ----------- Design Flow..............S ___..__._._�.``..,____-----gallons per person per day. Total daily flow____._.__._._. !o_.__..___._...__.__gallons. WSeptic Tank—Liquid capacity-{tl'..gallons Length................ Width---------------- Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.........._._..q.. Total leaching area..-._.__ .........sq. ft. Seepage Pit No-----------l--------- Diameter.._....� Depth below inlet......... ....... Total leaching area.... ?......sq. ft. Z Other Distribution box ( ✓S Dosip tank-� Lj ) �u A.-JO �Percolation Test Results Performed by_ ----- . _1.-...+dV'a.(.. � te.............. . aTest Pit No. L-�.--------minutes per inch Depth of Test Pit! ............ Depth to ground water_______________________. (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to grounh,water........................ ----T---•-d- S---�------------•................•---------..__...-----•--...........--•--------.....-•-----------•--•--....._...---- 0 Description of Soil ---=�•-��-x W -------------------------------------------------------------------------------------------------------------------------------------•--------•--•--•-•---•-•--•---------------•---•-----------........ VNature 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:iT y g g p y of the State Sanitary Code—The undersigned further agrees not to lace the system in operation until a Certificate of Compliance has , bee&*ssuedbDy the oard of hea lth. Signe � Datt /`-APPlication APProved BY ..--•• --------------•--•-•-- ••-• -Ci Date Application Disapproved for the following reasons----------------------------------------------------------------------------------------------------------------- -----•--•-•--••••••----•-----------••-----••--•---------•---------•---••-------•-------------•----•-.......•------•------•--•-•••--•-•--------- --------------------------------------......---------- © ce Permit No..... Issued 7..��-�_..P"' ................... Dau Date THE COMMONWEALTH OF MASSACHUSETTS BOAF OF I-IEALTn T.iv.t ..............oF..... ..-1 A 4..C.-�.�..................................... Cwrrtifirate of Toutpha ttre T I TO4 ,TAF , t the Individual Sewa e Dis osal S stem constructed (►�or Repaired11a g P � Ins /'1 l. ....................................... --------------------------------------- h inst 11 in accordance with he rovisions f " r of.The State Sanitary Code as described in the as been .,.a cc t p � y application for Disposal Works Construction Permit N ___---_0..d.-. :__.__.. da.ted---..-�°_`: �...... .:............. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE........ °-_ .�-•-------------•----------------....------. Inspector..-.&- / .................. pt �� No......................... r ss. l....................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH t� � ....................OF...... -.....+�j i / � ._.. ApplirFation for Biipusal Workii Towitrnrtion ramit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System. at ......................... �'�an ....... c t ............................. ....-------------------....._......---•- � •= '-----.............-----...._. . Location-Addres or Lot No. ---------------------- -..._ �._........... :_•-•---------•-•-- ••-••••......_......-•-•••-.._.......---------••-••-••------•••-••----------------........-----_.. Owner Z Address ---- ................ Installer Address U Type of Building Size Lot.____ -1 1AG...Sq. feet Dwelling—No. of Bedrooms..........�Z..............................Expansion Attic ( ) Garbage Grinder ( ) PA Other—T e of Building No. of ersons________________________ Showers PA YP g ---------------------------- P ---- (---)--- Cafeteria.(...... ._). Other fixtures ---- ------- --------- --- -- -- --- W Design Flow.............. '="�_____.__._ ___._....__gallons per person per day. Total daily flow_._._..._.__. - _________._______..gallons. WSeptic Tank—Liquid capacity __gallons Length................ Width................ Diameter___..._.._.._.__ llepth____.._____.._-- x Disposal Trench—No_ ____________________ Width.................... Total Length............ _ ..... Total leaching area......y7..........sq. ft. Seepage Pit No__________ __________ Diameter........ --------- Depth below inlet......... _.___. Total leaching area.....!~ a...sq. ft. Z Other Distribution box ( v")' Dosin tank ( ) '-' Percolation Test Results Performed b U *�'; 1.1JI ,.a Test Pit No. 1... ........minutes per inch Depth of Test Pit_!_ _____________ Depth to ground water-------_______--_. 444 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------ 2--•--- of - -�----A - -----�---- x Description of Soil �______t", ! �P.--...--- t t4h�...•----•--•••--, 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 T`:?:J p 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. Signe.i -• - ---------------------------------•------•------------------•----•---- ................................ pp Da Application Approved By...... .. -- ---•- l• -----------------•-••- .....X-..../S'- CI ---------••••••••- Date Application Disapproved for the following reasons_......._.................... .................................................................................... --•-----•-•-----------------••---•---•-..•----------------------•------------------•------•---------------••••-•--••-••••••••••••-••-•-•-•-•-•-•-------•••----•-•--•----•...••••---•---•••••--•_.._.._. Date PermitNo......................................................... Issued................................................._...--- Date +a THE COMMONWEALTH OF MASSACHUSETTS T BOA OF HEALTH ..............OF...t.....'�.°� ..?..A,C.0 Tnrtifiratr of TompliFanrle T TO - IF ; hit the Individual Sewage Disposal System constructed (--,.,,'Or Repaired by a ins ------ -______--•------------------------•-•--- at t1 �'�-r -- ' � � y` � �1 ---------------------------- has been install d in ccordance with the provisions bf T + r of The State Sanitary Code as descrilaed in the application for Disposal Works Construction Permit No ___ U_ _'............ da.ted------?_-`--�Y''�______!_____________ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. -- --------- DATE:............... Inspector.......f----'2�-- x THE COMMONWEALTH OF MASSACHUSETTS BOAR OF HEALTH .�............ OF............ .....:.f���.p.�r'`�-------..-:.-..-_.._-.........-. 3d µme✓ No......................... FEE........................ Dispo Inr inn Uan erntii Permission is-hereby granted••-•-•• •••-• • -•••- . • --••• --------------------------------•---------------•-••••••....•••-------•-•••- to Construct or Repai R an nd�i`'dual Se 'a e is sal Sy Street as shown on the application for Disposal Works Construction Pe m-i}�No..-._,_ _.__. . _ Dated_._. ••-••••••i� ---•-- -- - . .-- _ .................................. Boa of Health DATE........ ----------------- FORM 1255 HOBBS & WARREN, INC., PUBLISHERS '�- �. ' "+ { - s I Rom•�l�.►.! Zth,'i"�. _ _.._- . ` �.-�- --- ���.:....1-,�:----_•�,--art. �r� ��j� �.}�' ' +,.t:� C�AfLt::AGI:-: E�i s.tr✓�c�. C) P kl c5C7o f Q•t_. x 95 a ZIP. ��� P:'�� b1_ _T>iT , - �" �t/As_.L. �•� - 17O' S.F. �' • �., _,- !t►f 3/� �.P.17. `T Q.. So (a.P a.. TOTAL 'DES%6Q 415' Cr•P.i>. 7 oTn t_ ��t t...�f t i-Ln� • 33n�.P.'D• -- '. � �'•-_'.�.:._ :`�+� i- •��� _ '!d. CIQ SMI0 OtZ t L.�7"z1a ► w;; �I w� fit: t�.I /`j,Sj ,�//�j[�"�J t Tor T7-4o LoA4Aj 'PPe - 5�asa,f,.. 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