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HomeMy WebLinkAbout1026 RIVER ROAD - Health 1026 RIVER ROAD, MARSTONS MILLS A= 045 031 -ti� - - - - - -- 1 1' ,--',--ssor's map and lot number ........... F THE T /f d6ard,of Health Ord floor): �� ( _ f ~ ���p�- �-��t Sewage Permit number ©N � `3"� �` � yu Engineering Department Ord floor): �� K' " '� ;EARIST1111"d LE.House number 1 , . .... �dy APPLICATIONS PROCESSED 8:30-9:30 A.M. .and 1:00-2:00 P.M. only --! TOWN OF BARNSTAB ���, y WAED SIN NI-INSPECTOR WITH °�"�''-'�'� ► �a APPLICATION FOR PERMIT TO G R �� 4...a »4.........�e c k IRONMENTAL .......T.WKREtTia UI AT p AND TYPE OF CONSTRUCTION .......:. Q,QQ�,,,, 2 ! wt........:.................................. S Q TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ........ p ' .........LYa�.2.s. .S?'Y.s....... lls........................... /� .............................................. C� Proposed Use 4.12q. ....... Zoning District ....... . ..a. .......................................................Fire District .....1. 0 / 1 .................................... Name of Owner ...!'7rv-l'........!.�d,2,aL.!-W.............................Address ` ��yy pp 1........... ................. Name of Builder .t'1 D,AQU. - $. .� Q�.tt!L.S Address ..6.o. .......577 l �' ��. a�✓T.T1....... �. ..... V.. U 1 T^.... ................ f Name of Architect Wm.,fJ.Q,......................................................Address ............................... Number of Rooms � Foundation iAsP� Exlerior� ..................................................... ...................Roofing . . . .. ...................................... i Floors Interior ....................................................... Heating .... Plumbing .t.0............................... . ............ ....................:.. ............................................... Fireplace ..P1/ ......Approximate Coj.a.( ,�Q .. .............................. ...... Definitive Plan Approved by Planning Board --------------------- --- 9-------- • Area *� (�/' 7...[ ... .................... Diagram of Lot and Building with Dimensions Fee .......... .... .............. SUBJECT TO APPROVAL OF BOARD OF HEALTH h.t _commornweotih-of-Mosscic wsetts John Grad Executive-Office of ErMrorn*inhai Affairs D.E.P. Title V Septic Inspector Department- of P.O.-Box 21-19 vi Teaticket,MA 02 536En l af (508) 564-6813 O 3 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM — -- PART A CERTIFICATION k 41, Property Address: 1026 River-Rd.Marston Mills:House Address of Owner: 1 �- Date of Inspection:7111196 (If(jifferent) ►6:&v. Name of Inspector:John Gracl Fitzgerald Company Name,Address and 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: x Passes _ Conditionally Passes Needs Furth r E luation By the Local Approving Authority Fails Inspector's Signature: Date: 7112196 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTEM PASSES: x I have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: _One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined(Y, N,or ND). Describe basis of determination in all instances. If "not determined", explain why not.) The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved'. by the Board of Health. (revised 11115195) One Winter Street . Boston,Massachusetts 02108 • FAX(61T)556-1049 • Telephone(617)292-5500 —_ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A -CERTIFICATION (continued) - Property Address: 1626 River Rd.Marston Mills:House - `- Owner: Fitzgerald — Date of Inspection:7111196 _ Sewage backup or breakout or higli static water level observed in the distribution box is 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 leveled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with-approval of the Board of Health): - broken pipe(s)are replaced obstruction is-removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone 1 of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria volatile organic compounds indicates that the well is free from pollution for that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm. 3) OTHER D] SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage in facility or system component due to an overloaded or clogged SAS or cesspool_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged cesspool. SAS is in hydraulic failure. (revised 11115195) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - _ PART A - CERTIFICATION (continued) Property Address: 1026 River Rd.Marston Mills:House Owner: - Fitzgerald Date o4-Inspection:7111196-- D] SYSTEM FAILS(continued)- Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS-or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow-. .= _ Required pumping more than 4 times in the last year NOT due to clogged or obstructed_pipe(s). Numbers of times pumped - Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within-100 feet of a surface water supply or tributary to.a surface water supply: Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria: _ The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area (IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 11115195) 3 SJBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART B CHECLIST Property Address: 1026 River Rd.Marston Mills:House Owner: Fitzgerald Date-of Inspection:V11196 Check if the following have been done: - - - - x Pumping information was requested of the owner,occupant, and Board of Health. x None of the system components have been pumped for at least two weeks and the and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part-of this inspection. X As built plans have been obtained and examined. Note if they are not available with N/A. I X The facility or dwelling was inspected for signs of.sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout. x All system components, excluding the Soil Absorption System, have been located on the site. X The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. X The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. X The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11115195) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C - - SYSTEM INFORMATION - Property Address_ t025 Rlver Rd;Marston Mills:House Owner: Fitzgerald Date of Inspection:7111196 FLOW CONDITIONS RESIDENTIAL:.__ Design flow. 330 gallons - Number of bedrooms: 3 _- Number of current residents: 3 Garbage grinder(yes or no): Yes - Laundry connected to system(yes or no): Yes - -Seasonal use-(yes or no).-No. Water meter readings, if available: Na Last date of occupancy: n1a - COMMERCIAL/INDUSTRIAL: Type of establishment: nta Design flow:o gallons/day Grease trap present:(yes or no)_Ho Industrial Waste Holding Tank present: (yes or no) No Non-sanitary waste discharged to the Title 5 system: (yes or no) No Water meter readings, if available: n1a Last date of occupancy: n1a OTHER: (Describe) nla Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System was last pumped Four years ago. System pumped as part of inspection: (yes or no)No If yes,volume pumped: 0 gallons Reason for pumping: n1a TYPE OF SYSTEM X Septic tank/distribution box/soil absorptions system Single cesspool Overflow cesspool Privy Shared system(yes or no) ( if yes, attach previous inspection records,if any) Other(explain) APPROXIMATE AGE of all components,date installed(if known)and source information: 1984 Sewage odors detected when arriving at the site: (yes or no) No (revised 11115195) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM _ - PART C SYSTEM INFORMATION(continued) Property Address:. 1025 River Rd.Marston Mills:House - Owner: F_Itzgerald - - _ Date of Inspe.ction:7111196 - TIGHT OR HOLDING TANK: _- (locate on site plan) Depth below grade: Na _ Material of construction:X concrete metal FRP_other(explain) Dimensions: Na Capacity: n1a gallons Design-flow: n1a gallons/day Alarm-level: n1a Comments: (condition of inlet tee,condition of alarm and float switches, etc.) Na DISTRIBUTION BOX: X (locate on site plan) Depth of liquid level above outlet invert: Liquid level with bottome of pipe. Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box etc.) D-box is structurally sound. PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no)No Comments: (note condition of pump chamber, condition of pumps and appurtenances. etc.) nla (revised 11115195) 7 „&M 3xf,..- rh 'r3s .... .- ` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C _ SYSTEM INFORMATION (continued) -- _ P ro pe rty Ad d ress: 1026 River Rd;Marston Mills:House Owner: Fitzgerald Date-of Inspection:7111/96 SOIL ABSORPTION SYSTEM (SAS):X (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: _ n1a Type. - - leaching pits, number: n1a leaching chambers,number:2-Flomidiffusers. leaching galleries", number: n1a leaching trenches,number,length: n1a - leaching fields,number, dimensions:n1a _ overflow cesspool, number:n1a Comments:(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.) Sas is functioning properly. CESSPOOLS:_ (locate.on site plan) Number and configuration: n/a Depth-top of.liquid to inlet invert: n1a Depth of solids layer: n1a Depth of scum layer: n1a Dimensions of cesspool: n1a Materials of construction: nia Indication of groundwater: n/a inflow(cesspool must be pumped as part of inspection) nla Comments:(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) n1a PRIVY:_ (locate on site plan) Materials of construction: n1a Dimensions: nia Depth of solids: rva Comments:(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) Na (revised 11115195) 7 7 �. ca `%Y' 'M.rs,x ».. �'y t r=.� .:.? xrs..r �3P .+ ,t ws�a lt`, 3 _ ?;7.,i� .$,• E�?i, ._ "t. yl N,�,. , 4 ,.. Y f a v� t+, r" S� F t" 3 r yg rs _ SUBSURFACE SEWAGE DISPOSAL SYSTEMiNSPECTION FORM - PART C . . SYSTEM INFORMATION--(continued) Property Address: 1026 River Rd.Marston Mills:House _ _ Owner:. Fitzgerald — Date of Inspection:711119e SKETCH OF-SEWAGE DISPOSAL SYSTEM.: - include ties to at least two permanent references landmarks or benchmarks - locate all wells within 100' JA fS� �y �9 A p $7 I-f � ��'c 71 DEPTH TO GROUNDWATER Depth to groundwater:12 feet method of determination or approximation: t1SGS MAPS AND CHARTS (revised 11115195) g I TOWN OF BARNSTABLE LOCATION%® —C (Z\V&l, e� SEWAGE #4:4�eg_!GAF . .r VILLAGE ymL-c-5 ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. (_QeS . C�+•�"(. SEPTIC TANK CAPACITY 1600 + f�. LEACHING FACILITY:(type) -a E44-0_ u S (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER PG-�c BUILDER OR OWNER (Zt W R/ DATE PERMIT ISSUED: LATE .COMPLIANCE ISSUED_ VARIANCE GRANTED: Yes No g 644 1{ � r 31 No...g YR513 ..................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 63 ...............OF........ -------......................... 6 Appliratiou for Dispviial Works Towitrurtion Prrmit Application is hereby made for a Permit to Construct (/) or Repair an Individual Sewage Disposal System at: ................ ................................................................... ------ 7--------------------------- ........... .. e------... ................ 0 .............. Address Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms............. .............................Expansion Attic Garbage Grinder P-4 44 Other—Type of Building ............................ No. of persons............................ Showers Cafeteria 114 Other fixtures .................................................................................................. �4 -----------------------------*-------------------- W Design Flow............................................gallons per person per day. Total daily flow..........................................gallons. 1:4 Septic Tank—Liquid capacity............gallons Length................ Width.......------... Diameter...-.-..-------- Depth....--..--...... Disposal Trench—No..................... Width.....--............. Total Length.................... Total leaching area....................sq. ft. Seepage Pit No-------------------_ Diameter......--.--......... Depth below inlet.--..........._..... Total leaching area............--....sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit---.--..........--.. Depth to ground water---.-..----.---.----_--. f1 Test Pit No. 2................minutes per inch Depth of Test Pit--................_. Depth to ground water------------------------ 04 --------------------------------------------------*-------------------------------------------------------**------------------------------------------------- 0 Description of Soil................................................................0....................................................................................................... x U ......................................................................................................................................................................................................... W ----------------------------------------------------------.............................................................................. --------------*-----------------------------------*....... U Nature of Repairs or Alterations—Answer he 1* able-- ------- A/�(,J------- tn.u��..t4c . 0, if........... ........... ........ ...................... .........al.A................qiz;�--------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'T'LL 5 of the State Sanitary Code—) e undersigned further agrees not to place the system in operation until a Certificate of Compliance has been iss the board of health. Signed.---- --...ems ...... .. ....q=l.............. Date ApplicationApproved By.................. .. ...ZLCI.Z6�..... ......................... .......... .....I....... Date Application Disapproved for the following reasons:................................................................................................................ ..........................0.............................................................................................................................................................................. Date Permit No.------. ... 5 . ..................... Issued....................................................... Date dam¢Q ~ '� No....J,12.: T FRs.... ........ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .............OF...........1 Appliration for Uigpnaal Works Tomitrnrtiun randt Application is hereby made for a Permit to Construct (1/) or Repair ( ) an Individual Sewage Disposal System at• - -/ �.:........................ �S�il..�--- / Gf�` anon-Address //J� /� _ : Address Installer Address UType of Building I Size Lot............................Sq. feet �-, Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) 04 Other—Type of Building ............................ No. of persons........................--.. Showers ( ) — Cafeteria ( ) Q' Other fixtures ............................... . . w Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 1:4 Septic Tank—Liquid*capacity............gallons, Length................ Width................ Diameter.....--......... Depth................ Disposal Trench—NTo..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter..................-. Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ ,a Test Pit No. 1----------------minutes per inch Depth of Test Pit.------............. Depth to ground water-.----.------------.---. fT Test Pit No. 2................minutes per inch Depth of Test Pit---................. Depth to ground water................_--.---. a •••--•-•--•------------•----••-••••-••••--•••••-•••-•••--•-.........--•--•------•.................•-----.....-•••-••••-----••••---•--••----••-•-•-•••---•--•- ODescription of Soil........................................................................................................................................................................ x U ............................•••--•-•--••----•-•---•----------•----•--•--•----------•.....-•---•-•••----••••-•----•••--•-----••••--•---••----••--••••---•••••--•---••--•......-•-------•--.............. w UNature of Repairs or Alterations—Answer when a cable_-.--. __��f��f �_._... ._.- - l 'h........... .......�� Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'TTLE i 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 he th. Signed........�� 4 .............. ....... •- Date ApplicationApproved By......................................... ........................................ Date Application Disapproved for the following reasons:-------•------------•---•-------------------------------------•------------------------------•••------........_ ................•---...---------------•-----------------------••----•-----...------------......--------...--....---...--.............------•------••---------------------------------------------------•. Date PermitNo-------------------------------------------------------- Issued...................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF nHEALTH /J ................OF.......���. O.W. I' /`�C�I.!.-ei............................. (Irrtifiratr of Tomphatta THIS IS TO C RTIFY, That the Indio ual Se. 'age Disposal System constructed (I/) or Repaired ( ) by---------------------4c= ir------�`��??5.:.... ,/fir 2....9- Installer at //Q �f �'(�..y/.5/�j..l �.....................�.--------•----------- 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 CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE...................... ..................................... Inspector....................... = THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .... ...............OF.....- rlG7...U. .......................... 2,�5 NO......................... FEE........................ Disposal Vorks Tnntrnrtion Vermlit . Permission is reby granted......... .......4y";rl. -..... A'��.....���................................... to Construct (I ) o Repair ( ) an Individual Sewage Disposal System treet as shown on the application for Disposal Works Construction Permit No..................... Dated.......................................... •----••---------•-------•----•-•----------------------------------------------------•---.....--------•-- Board of Health DATE................................................................................ FORM 1255 HOBBS & WARREN, INC., PUBLISHERS -L O C f�'ION SEWAGE PERMIT NO. 4;r4q-? yc 2 rj Rig LV4110 VILLAGE x}s !jj J�&lsl I A L ER NAME i ADDRESS L 461 ROUTE GA P. O. BOX 4X EAU BANIDWICH. MA 0163'J e U 1 L D E R OR OWNER I� DATE PERMIT ISSUED 0 DAT E COMPLLANCE ISSUED o/ Lam' L a� r . �� Y -� � �� ,. I � ,. ., � �p _. r �� .. ..� k �- -�_.� f THE COMMONWEALTH OF MASSACHUSETTS BOARD tQF HEALTH �,r �CJGc ...........o F...... . .. .............................. Appliration for Disposal Mortis Ton.strurtion famit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal system I: Z/ A '=•n d res..,CX. ....f A.................W ....... � -..�`� .....�r d .4�:.:::•::..»........... 1- .. w ... .............. ........-•-...Address a ................................................ ......----................ .... Installer Address Type of Building Size Lot....... .. .OSq. feet U Dwelling �No. of Bedrooms...��. ...................................Expansion Attic j Garbage Grinder Other—T e of Building No. of persons............................ Showers — Cafeteria a' Other fixtures .. W Design -- Flow...................... .•- - lons er erson�j da T otal it flow............E�.....�..�...._.......... �oiis. G ------- WSeptic Tank—Liquid capacity. >_gallons Length...... _ Width. ... Diameter................ Depth. .:..9� x Disposal Trench—No. ...../........... Width....Id........ Total Length..':'...: Total leaching area..69 ....sq. ft. 3 Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area.................sq. ft. Z Other Distribution box DosingtV*0-4 ( Percolation Test Res s Performed by.._..._L).& �E..... Date_.:::. .. .----- ,al Test Pit No. 1.�.�..minutes per inch Depth of Test ...'. ........... Depth to ground water_. ................... y G4 Test Pit No. 2................minutes per inch Depth of Test Pit....../Q...... Depth to ground water.XC.j J 04 4•.. -•--••--••...... ..................... •,................... . O Description of Soil......•.. ... .. , .��,��....... -� .... l .. �........... U --- ----------------•-----------------... ........ ... •- VW .......-••-•--•----••-•-------•--.... --]?.... -- ----------------- .............................:-.......................................... Nature of Repairs or Alterations—Answer when applicable............................................................................................... -----------------------------------••----...-----•--...............----.................--------•------••------•------------------------....................-----......---......•--•---••---............ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the pro•' 'ons of TITLE 5 of the State nitary Code— The undersigned further agrees not to place the system in oper ion ntil a rtificate o Co4np1' c has been issued by the board of health. gned R st ...4!�!.LC- M�-Oj............ ...� D ApplicationApproved :. ...---•-----------------------•-•------------------------......----- -•--.. •--L- ..................... Date Application Disapprov or t e following reasons------------------------------------------------------------------------------------------------•-----.....--- ...............................••---......................._._..--••-....................----•---•-------.....---•---•••--•-•--•-•---•........._..-•••••.....-•--•-•-••........-••--•............•---•-- Date PermitNo..................................................._.... Issued................ ................_.......--.------- Date r , THE COMMONWEALTH OF MASSACHUSETTS BOARD F HEALTH OF y � ... ....................................... Appliration for Disposal Works Tonstrixrtioit PmAit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Syst,=)a : / V R � » o .tion ...,�,,�...... '; ........ :�'/ ..................... ....(—�.. ...`....�. .... '•"' T=='= •"'� �= --- • Owner Address W Installer Address (' Type of Buildin Size Lot......a. ...;.. .,, Sq. feet ' V Dwelling o. of Bedrooms___,..................................Expansion Attic , Garbage Grinder `4 Other—Type of Building No. of persons............................ Showers — Cafeteria Q' Other fixtures ----_•------•--•--------•...................... r Design Flow..................... .`?.. gallons per person =-- .. .� � . ie day. Total daily flow............t ............ Septic Tank—Liquid ca acit . -LbaIons Len ----•- �. Width.y:1C).. Diameter................ llePth..V..=-." Disposal Trench—No.......j........... Width.....Id........ Total Length... ._ .... Total leaching area-.,K4- r)....sq. ft. 3 Seepage Pit No..................... Diameter.................... Depth below inlet...:................ Total leaching area.................sq. ft. Z Other Distribution box ( ... Dosing tor—/ Percolation Test Results Performed by.. /l r a t t�JCC � �=` " =' Date_.. .:. :.r ....... Test Pit No. 1. .. _..minutes per inch Depth of Test tLY:?___ ........ Depth to ground water__,?!............. G>~ Test Pit No. 2................minutes per inch Depth of Test Pit......./6...... Depth to ground water...C_LtJJ P..+�/a -- -- --------- O Descriptionf Soil ...._.. .f ...t ` e .......................•�, -..... 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 pro olls of T I T IE 5 of the State nitary Code—The undersigned further agrees not to place the system in opera on ntil a rtificate o Colt c as been issued by the board of health. 1` ned... ..................... ..... Dat ApplicationApproved,B :. s.. ........................•--•----------•--•-----•................_ .... . Date Application Disapproved th ollowing reasons:...........................................................................................................--- .......................•-----•----------•--•-.....-••--•---------•-•...........•--•-........----•--•...».-••--•••---•-••-•-••------•------------•-........--------•---.........-••----------•••--.....» Date Permit No............... Issued....----•------.....-----•-•-•-......--•--............. ..............•-------.........._.... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF....................................................... ......................... Trrtif iratr of Tomplianrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( r Repaired ( ) 1 Installer at. 6;�_e_d oe... .. ------------•---•..-•--• -----------•--•-••-•----•-•---------•------------- ------•---- has in accordance with the provisions of TITLE j of The State Sanitary Code s de I ed in the PP P " ".`S l T .applicationDisposal 2/-. - i THE ISSU NCE F THIS CERTIFICATE SHALL NOT BE CONSTRUED S UAR NTEE THAT THE SYSTEMMWL U CTION SATISFACTORY. DATE... ... ... .............................................. Inspector...... . .. ....-----•-•--•----••---•--•----•---................................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No. :.., f .. ..........................OF................................----............... - ............................ F>a�..... Q............ ` Disposal Works T trud* n, lerntit Permissionis hereby granted...............• ..... .._.._... ......... ....................._..................................................--- to Construct „ r Re ' ) an iv' ual Sewage Disposal System Street as shown on the application for Disposal Works Construction Permit No................. ..,. . ._. .. ................ .............X.......................,,e. ...... •.fit..!:. ..............._...............» oa o � DATE...--" 4Z...-/ :_ _........................................ B. Health:. FORM C-1255 CITY& TOWN FORMS, INC. 369-9708 L41 ILI 41 - In, 0' CQ 4A-T- LOT 4- IiOT LO L cn, LOA,li LAJ Pc) PAI IN Ll 0 ct - - - 00 Jell- tam.(, V�3 T.H 1L A* 10 P.4 U Vic= A.1__ i v � '`'z- ;i \ y _ (�} L v L_CjT -?— H SF L C>T' 7E T_ W-)L Z_ w v c-00 C5 PE a "T V_Iti�L RE ki 4r- TN T 0<7T IWV P-o K --p rj�- V_ -T—z, - q ea `v...-. r.+�-. wf v St c�1 i- Y `uw �'�� "t x wA Left 3 \-ZAw\ vE ZA xv 7-0 TA. 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