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HomeMy WebLinkAbout1401 OLD POST ROAD (CT & MM) - Health 1401 Old Post Road Marstons Mills - A 057 -025 TOWN OF BARNSTABLE Pic - 6&pr > , LOC ATION //0/ D SEWAGE # VILLAGE ESSOR'S MAP & LOT i INSTAtLLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY ®@� LEACHING FACILITY: (type) 1,660 .ot?' (size) NO. OF BEDROOMS BUILDER OR OWNER &W,44D '304Co a PERMITDATE: COMPLIANCE DATE: r 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 ���G�tJ `®le J ' o i L0CQT N SEWQC,E PERMIT UO. VILLAGE 1I�l�,TQLLER S U&ME ADDRESS 59JLDER5 Q &VAE ADDRESS - =32 Gvi.9��a lko — DNTE PERKA T ISSUED ATE COP/IPLI AI`lCE ISSUED: — — l 0 ti N oa W / cm --------------------------------- COMMONVY'EALTH OF MASSACHUSETTS z EXECUTIVE OFFICE OF ENVIRONMENTAL,AFFAIRS. - .c DEPARTMEITT`OF`:ENUIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM-FORM PART A CERTIFICATION Property:Address: � 'J �T" L���� �G� d�' az4ml Owner's Namel Owner's Address: ( Date of Inspection. . (1 '4 ` �� 9 Name;of Inspectr: please print) (yt T""r �"�—j �� t Company Name: a. J2 ��LZ?,�Y9 e Mailing Address: 4 ;v /tC 00 Telephone Number: 6*4 CERTIFICATION STATEMENT 1.cerify 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 maintenance of on.site sewage disposal systems.I am'a DER approved system inspector pursuant to Section 15.340 of Title 5.(310 CMR 15.000). The system Passes - Conditionally Passes { Needs Further Evaluation by the Local Approv:inQ:A-uthority l Inspector's Signature:. �' f Date: �/ � •� d. The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of.completina this.inspection. If the system is a shared system or has a design flow of 10,000 gpd cr 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 ****`!'his 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. Title, Inspection Form 6/15/2000 page I Page 2 of 1.1 OFFICIAL INSPECTION FORS-NOT FOR VOLUNTARY A.SSESSiV1ENTS SUBSURFACE SEWAGE'.DISPOAL SYSTEM INSPECTION ]FORM PART A CERTIFICATION (continued) Property Address:�y P t f rL A Owner• .Date of Inspection: _ �> r Inspection Summary: Check .A,B,C,D,or E./ALWAYS complete.all of Section D A. System Passes: V/ I have not found any information which.indicates that any of the failure criteria described in 310:CMR Y5.303 or in 310 CI41R 15.304 exist. Any failure criteria.not evaluated are indicated below. Comments: B. _ System Conditionally Passes: One or more system components as described in the"Conditional Pass" section needto be replaced or repaired.The system, upon completion of the re lace P Y Preplacement or repair;as approved by the Board of Health;will pass. Answer es no or n det ermined termined Q y (Y,N;ND)m the for the followm�statements. If not determined"please explain. The septic;,tank is metal and over 2.0 years old* or the septic tank(whether metal or not) is structurally unsound,exhibits substantial.infiltration or exf Itration 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 . ND explain: 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 ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM-. NOT FOR VOLUNTARY ASSESSMENTS SUBSUR��A.CE SEWAGE.DISP:OSAL SYSTEM'INSPECTION` ORM PART.A CERTIFICATTON (continued) Property Address: Owner Date of Inspection: 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 fading 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 healthi.safet."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 salvmarsh 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 aseptic tank and soil absorption system (SAS)and the SAS'is.within 100 feet of a. surface water supply or tributary to a surface watersupply: _ The system has a septic tank and SAS and the SAS is within a Zone l ofa public water supply. _ The system has a septic tank and SAS and the SAS is within 50 fe'et of a,private:watersupply well. _ The system.has a septic tank and SAS and the SAS is less than 100 feet.butv0 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 poifution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided thatno other failure criteria are tribeered. A copy of the analysis must be attached to this form. 3. Other: 3. Paee 4 of.I I OFFICIAL:IlVSPECTION FQRtvI- .NOT FOR VO]LUNTARY-A.SSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property.Address: 4 ! ' Owne Date of Inspection: 0 D:.. System Failure Criteria applicable to all systems'. You must indicate"yes')or"no"to each-of the following for all inspections: Yes' No Backup of sewage into:facility or system component due to.overloaded or clogged SAS oc.cesspool 712 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 leveliin the distribution box above.outlet.invert due to an:overloaded or.clogged SAS or cesspool Liquid depth in cesspool is Jess.than 6 below invert or available volume is less than %day flow — Required pumping more:-than 4 times in.the last year NOT due to clo-yed or obstructed pipe(s).Number /. of times pumped y� V/ An portion of the.SAS cesspool.o Q — Y P ,. pool. r privy is.below high round wate'.elevation. _ Any..portion of cesspool or privy is within 100 feet of a surface water supply or tributary,to a.surface water supply.. An portion of, cess ool.or Y P p , .privy is within a Zone 1 of a.public well. An. `portion o� a'_f y p f cesspool_or privy is within:�0 feet ofa. rivate water supply-well; - . P Y P PP Y. i1 Any portion of.a cesspool or privy is:less than 1.00 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 DEP certified laboratory, for colifor.m bacteria and:volatile organic compounds indicates that the.well is free from pollution'from that.facility and the-presence of ammonia nitrogen andnitra.te 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.] (Yes/No)The system'fails. I have determined that one ormo e� , r of.the above failure criteria exist as described irr310 CMR 15.303,tlierefore,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 larger system the system must serve a facility-with a design floe of 10;000 gpd to 15,000 gPd- You must indicate either"yes" or"no."to each of the following; (The following criteria apply to large systems in addition to the criteria above) yes no _ the systern it within 400 feet of a.surface drinking water supply the system is within 200.feet.of a tributary-to a surface drinking water sup jly — _ 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 in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. Page of I 1 OFFICIAL INSPECTION FORM. NOT FOR'VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Y Address: y( J. CN ,' ' Owner., y Date of Inspection: Check if the following have been done.You must indicate"yes"or"no" as to each of the followtn2 Yes."'-No Pumping.information was.provided by the owner, occupant, or Board of Health 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? 1 Have large volumes of water been introduced to the system recently or as part of this inspection-:�/7/ ?. Were as built plans of the system obtained and examined? (If they were not available note as WA) Was the facilitydwelling inspected for signs of sewage back u or. weg� p b y p . — Was the site inspected for signs of break out? Were all system components, excluding the SAS,.located.on site Were the septic tank uncovered;opened; and the interior of the tank inspected for the condition of the ffles 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 no Existing information.For example, a plan at the Board of Health. �f Determined in the field.(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) (310 CMR 15:3020)(b)] Ne 5 Page 6 of I OFFICIAL INSPECTION `FORM NOT FOR VOLUNTARY:ASSESSMENTS SUBSURFACE SEWAGE:DISPOSAL:SYSTEM INSPECTION FORM PART C SYSTEM INF.ORINTATION Property Address: I � ;f Date.of Inspection: _ 60 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):-._n Number of bedrooms(actual): j d DESIGN flow:based on 310 C �R 15.203 (for example: 110 gpd x n of bedrooms): Number of current residents:: Does residence have a garbage grinder(yes or q141 _ . _ Is laundry on a-separate sewage system (y s or no). f ves separate inspection required] Laundry system inspected ( e .or.no): (� Seasonal use: (yes or no): U Water meter readings, if ay lable(last 2 years usage(,,pd)):. aq'2 07av o Sump pump (yes or no): .0 4._ Last date of occupancy:Ml IOLA, JG l%�'•�(> / 'I 6 COMMERCIAL/INDUSTRIALAA) Type of establishment:: Design flow(based on 3,10 CMR 1-5.203): gpd Basis of-desip flow(seats/persons/sgft,etc.): 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/user OTHER(describe): GENERAL INFORMATION Pumping Records f Source of information: J_t,4,)1 lae.lvl Was system pumped as part of the inspection(yes or no): A If yes, volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE/OF SYSTEM _L/Septic tank, distribution box,soil absorption system V Single cesspool _Overflow cesspool _Privy - _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) —Tight tank Attach a copy of the.DEP approval i.Other(describe): Apgr imate age of all omponents, date installed(if knpwn) and source of information: `? �� . _ - Were sewage odors;detected when arriving at the site (.yes or no): 6 Page 7 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART C SYSTEM.INFORMATION (continued) Property Address: Own- ��- ' Date of Inspection: BUILDING SEWER(locate on site plan) 1A11(). 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: ?t� Material of construction: /concrete_metal_fiberglass . .Polyethylene" —other(explain) If tank is metal list age:_ Is age.confirmed by a Certificate of Compliance(yes or no)'.`—(attach a copy of certificate) Dimensions: Sludge depth: 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: Distance from bottom of scum to bottom of outlet tee or baffle: �- r 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.): Y /(. d GREASE TRAP:Ablocate on site plan) Depth below grade: Material of construction:_concrete metal_fiberglass_polyethylene_other (expl"aiti): 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.): i Page 8 of I .'OFFICIAL-INSPECTION FORM—NOT`FOR.'OLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: .. � IA Owner: P Date of Inspection: TIGHT or HOLDING TANK:4U (tank rust be pumped at time of inspection)(loc.ate on site plan) Depth,below grade: Material of construction: concrete petal fiberglass Polyethylene - other(explain);_ Dimensions' Capacity: gallons 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:J—(if present`m,-lst.be opened)(locate on site.plan) Depth of liquid level above outlet invert l✓L✓��w'vtL /° A "'"te Comments(note;if box is.level and distriburon to:outlets ual;.any evidence of solids carryover; any evidence of .—Ital,cage into or out of box, etc) a �� PUMP CHAMBER:. Olocate on site plan) Pumps in working.order(yes or no): 1 Alarms in working order(yes-or no): Comments(note condition of.pump chamber, condition of pumps and appurtenances, etc.): t Page 9 of 1 1 OFFICIAL INSPECTION FORM.—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE-SEWAGE DISPOSAL SYSTEM INSPECTION FORYI PART C SYSTEM INFORMATION(continued) Property Address: �� ��� ( ✓ � !' }} Ce L _ Date of Inspection: lL' s SOIL ABSORPTION SYSTEM (SAS):Zoocate on site plan, excavation not required) If SAS not located explain why: Type lleachingp its,'number: —leaching chambers,number: =leaching.galleries, number: leaching trenches, number, length: leaching fields,number, dimensions: overflow cesspool; number: -innovative/alternative system, Type/name of technology: Comments (note condition of soil, signs of hydraulic.failure,level of ponding, damp soil, condition of vegetation; ly �../ L.�..a tC c�✓p l L '�._.e..X°✓// io ,s s CESSPOOLS:f 6(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: Mate_ials 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.): PRIZ'Y:.A/b (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.)- 9 Page 10 of 11. OFFICIAL:INSPECTION FORM=.NOT FOR V01,1JINTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM, PART C SYSTEM INFORMATION(continued) Property Address; f.. t f 01,j m A F . Owner: gyp' Date of Inspection:12,11 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all.wells within 100 feet.Locate.where public water supply enters the building. i • 01 I 0 10 Paae 1 I of 11 OFFICIAL INSPECTION FORM.-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE ]DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: /VN 6WA(100 41 A OwnerGto,'A' .g Date of Inspection: _ .., 006 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water. 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) VAccessed USES database-explain: u must describe how you established the high ground water elevation: a k 11 _ Permit Number: Date: Completed by: F. (/ HIGH GROUND-WATER LEVEL COMPUTATION. .. Site Location: �Ir/ 0A01 1�i� �<%� , Lot No. Owner: Address: Contrcctor: i c r Address Notes: STEP 1 Measure depth to water table to nearest 1/10 ft. ...................:....................:.:.::..:..:....................:..... .Date �!Z 'q month/day/year STEP 2 Using Water-Level Range Zone; and Index Well Mapa.ocate:;;,,,.., site and determine OA .Approprj.ate;index well OB Water level range zone ..........I........................... STEP 3 Using monthiy report 'Current Water:Resources Conditions °' determ me°current depth Pl/r� water.Level forindex well_,._..:..:.................. l _. month/year STEP 4 Using Table of=water=level-Adjustments for index::well=-(STf.P:2A),-:current-depth .... to water=..level f_or:index=well-(STEP 3), and water level zone.(STEP 2B) determine.water,level.:adjustment ........................................................ .................................. S-EP 5 Estimate depth,to high water by subtracting the water level adjustment (STEP 4) from measured depth.to water level at site (STEP 1) ..... ....................................:. Figure 13.7Reproducible computation form. 15 r� �_..1 b1�► a TOWN OF BARNSTABLE I� / o LOCATION #� ��� / 5 �29. SEWAGE # f�� ASSESSOR'S MAP_ & LOT INSTALLER'S NAME & PHONE N06� _Z<X�-� ' -3�?% A _ SEPTIC TANK CAPACITY T 5 n � LEACHING FACI.LITY:(tppe) (/ lJ _. 1 . NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER �� �t' DATE PERMIT ISSUED:. DATE COtiPLIP_NCE ISSUED: VARIANCE GRANTED: Yes No I I �1,� i ��, � m I� �/ r� `� No...ggl.j, Fxs..... ...... - THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........ .......OF................. w-�? 4 5.1 ........... Appliratinn for Biiipasal Works Tonotrurtinn Permit Application is hereby made for a Permit to Construct or Repair ( -) an Individual Sewage Disposal System at: ................_� o:�.... .. ........ c ..`.. .............. �s���t ------L. ....---................ oca'on-Add resur No. ................_ � ....__... ._..._.....-•- Z fl! -- ..� 's Wer ,� `►dam$ ,�, `°.,��/ Installer Address �23� Type of Building - Size Lot.................... ..Sq. feet Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) '4 Other—Type e of Building No. of ersons............................ Showers G4 YP g ----•---•-----------•------- persons ( ) — Cafeteria ( ) adOther fixtures .....................................12 • -------------•--------------.................--•......................_...._.._..•--•- W Design Flow________._._9..1_0..................gallons per pwwowg,jr Oy. Total daily Qpw__...........eta.��.__.;;� .............grlloRls. WSeptic Tank—Liquid capacity�00.Ogallons Length..-P..�?... Width:.4..(().. Diameter:............... Depth.co...4 Disposal Trench—No. .................... Width.................... Total Length....................Total leaching area....... q. x .s ft. 3 Seepage Pit No........k........... Diameter......t.. ..... Depth below inlet.-�,�--.:.S.7...... Total leaching area-� dq. ft. Z Other Distribution box �A_) Dosing tank aPercolation Test Results Performed b ..... .s. 1 ll LL'[7.. ........... Date.-41..�L.� ?..... 64 Test Pit No. 1...._.__�..minutes per inch Depth of Test Pit...,. .__ Depth to ground water.I ... . t ...... Y--11.U" Test Pit No. 2.._L2.._minutes per inch Depth of Test Pit....132_.... Depth to ground water... a ...................4........................................ .................t............... ................ ..... - -----...-........... L O Description of Soil...1_...._1;�.^...� _... D� CC�.4� a -! _...--`p= ` ...�-.._... e �t �► .............•--•-........ ............ w UNature of Repairs or Alterations—Answer when applicable.......................... .. ......�� ..••--•-•.......................•--------------------•--------------------------------.....---...---•---••-------........... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of AITIL 5 of the State Sanitary Cod —The undersigned further agrees not to place the/te em in operation until a Certificate of Compliance has b s ed by the bo of lie 1 Signed•�•• _-• --•••• . ... •---• ........................ D Application Approved By............... -- --- t "' •---•-•--•-•--•--•----•-•-•-- ....... !.-..li._.-...`T T.... Date Application Disapproved for the following reasons:............................................................................................................ -•-••......................•-•-••-----•----------•-•-------............---................----•-.......-•.......•-••-........-•-----•------•------•----••--------•------•------......................... Date Permit No...... -. _.. Issued..................... No..._4K 1YCf_ FEs..._7�?......''� THE COMMONWEALTH OF MASSACHUSETTS �I BOARD OFH�E, IAL_TAH _ i _....Q.W.0........OF................. `.. .-...._ �t Appliration for Disposal Vork..s Tonstrurtion JIrrntit. Application is hereby made for a Permit to Construct ��) or Repair ( ) an Individual Sewage Disposal System at ................»» T ZO .......6 . D �:l' © �-�l b STo�t s ........................................- - oca ion-Address - ` ................. & E� tZA, .�----------------- c i_. _; .1/l P •-} U1�`+S w �t(.� AdV a a ..........................:. .:...�!.:._....... _--.._..----------------------............. ----._....--------------•---..........-•---•------------•-----......_..........................••. pq Installer Address V Type of Building -3 Size Lot_Z3.3 .Sq. feet Dwelling—No. of Bedrooms____________________________________________Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures ...................................... __ W Design Flow.............t.... ...... .......gallons per s•n-�er day. Total daily flow............` .............gallons. WSeptic Tank—Liquid capacityl ��gallons Length___v_ n__. Width;.�q _1�._ Diameter________________ Depth_..... ..... x Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area....... __ sq. ft. w axe 3 _ Seepage Pit No...............:..... Diameter......(-z-_.___ Depth below inlet._�-�__.€.5.... Total leaching area....... vsq. ft. r z Other Distribution box ��) Dosing.tank aPercolation Test Results� Performed by..... dc.................... Date �......:. _ Test Pit No. 1................minutes per inch Depth of Test Pit__.._44-..,... Depth to groundwater.11_.�� ...Lk . k)o LL, Test Pit No. 2.__�-__minutes per inch Depth of Test Pit__._��.2__.... Depth to ground water_____ __________ a •-------------------------------------- --------------•-••-- ...,{......-_._. .. -----.... l 4 .._------ O Description of Soi -- !` `'.._ , 4 L(= -AL�_i`{� s.��'_b"_0.V9..................... --- --'.�E�°_---- c f Sty ._?�.��i` - emu G t 1,-•Rev .-�J�1.1 W -----...---•------------ = ------. ' .............. U Nature of Repairs or Alterations—Answer when applicable.......................................................... .................................... ---------------•--..._..----•----..........._......-_-••-- Agreement: Theeundersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of AITLZ 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been..sued by the board of�health. , �� /�Y Signed _ >____.._ � � !�.,... ...._w....:................... /�...........».._. Date Application Approved By----�---'� ,�..� - ,,, ,` .`= ..._... ...... Date Application Disapproved for the following reasons:............................................................................................................. ---•.....................................�......----..-.--•-----..._.___...._.._.._...--------•--.........-•-----•-------•---•----------•--------------------•----•--•--------.._..--•-----•-..._._..» Permit No..... '�•-' �� - Issued......................... .................................... ...... Date . ............... . .•-.ice.. .......... r+eooK,�,,.. n.••.••:-•.. >-s mw-•.ao-orm�- r.' THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......... ..........OF.......... �� !. D..N................................. Trrtif irate,of fauntpliattre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired ( ) by....................... '�. ?._•........ ...?u,� .. ................•-.........---_...•- nstallez at............... a _ -.a..---- -'�..... ._ -------O �1-----�-------------------------------------------------------------------------- has been installed in accordance with the provisions of TITLE j of The State Sanitary Code as described in the application for Disposal Works Construction Permit No........ .......... dated.............-__-............................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. f/ -M ) _Y -$, � DATE. ....................-------------------------------------------------------- Inspector.................................................................................... a v-mx.•T•a,*i�a.-a.�vc.s..+.a....ew..rc«.,,...v•,�••�.,•.•••!ram.. _ _ _. »a",�r ,• ............ l.YM104@w.i!._. ••••_,__.^sw..t,•••�•r�e!r�r ra-w�s.o sew on cer�.. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH - r- No.. ... FEE........................ Y Disposal Works Tnnstrnrtiun 11rrmit Permission is hereby granted............ Qv`"!--•-- '�r�4 -•------•---•..............................•---•-•-------............_.....__......-- to Construct (�or Repair ( ) an Individual Sewage Disposal System Street as shown on the application for Disposal Works Construction Permit » No f J �_,_____ Dated........................................».. ........................•-•--.... ------ ...................................................... Board of fiealt4 DATE.............................................................................. PP,er,.Z ti ; 2-0 I �r:1t�o`t4.tt> 5E t r �^}'` • 'r ,,tt • � V M13 Ilil., kI1T 3 z_t 1 _ M ttl , Z 1 i Z y a < a ` I L Tort - o n T 1 POP c� 24 , 1`i 7 7` z a tI `r r t � F , a � apt� 4 i r•f ni S aTuM M5L ti,1C�1D i I .: -. , , to , 91, t i ED_ t S P„W.SE JO Pt PE, PtTc. 14 I Fr ` t t1 ra�t�-a.�t✓��casr u�ti-r� t Q, • z T: a. 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