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HomeMy WebLinkAbout0763 SANTUIT-NEWTOWN ROAD - Health 763 Sarituit-Newtown Road Marstons Mills /f A = 028 - 008 • • V V y 9Gc w BORTOLOTTI CONSTRUCTION, INC. - V" 45 INDUSTRY ROAD,MARSTONS MILLS, MA 02648 i a 508-771-9399 508-428-8926 FAX: 508-428-9399 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: Date Of Inspection Inspector's Name: Owner's Name and Address: - /c CERTIFICATION STATEMENT: I Certify,that I have personally Inspected the Sewage Disposal System at this address and that the informa- tion-reported below is true,accurate and complete as of the time of Inspection. The Inspectioin was perform- ed based on my Training and Experience in the Proper Function and Maintenance of On-Site Sewage Dis- posal Systems.The system: Passes 7-conditionally, es Needs Fur er valuati(W y the Local Approving Authority Failure' Inspector's Signature p g Date: TheSystem Inspector shall submit a copy of this Inspection Report to the Approving Authority with Thirty (30)Days of completing this Inspection. If the System is a Shared System or has a Design Flow of 10,000 gpd or greater,the Inspector and the System Owner shall submit the Report to the appropriate Regional Offie 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: • A) SYSTEM PASSES: I have not found any Information which i udicates that the System violates any of the fail- ure criteria as defined in 310 CMR 15.303. Any Failure Criteria not evaluated are indi- cated below. r B) SYSTEI*CONDITIONALLY,PASSES: t/ One or,more.System Components need to be Replaced or Repaired. The System,upon completion of the Replacement or Repair,Passes Inspection. Indicate yes,nor,or.not determined(Y,N,OR ND). Describe bases of determination in all instances. If"not determined",explain why not. The,Septic Tank is Metal,Cracked,Structurally Unsound,shows Substantial Infiltration or exfil- tration,or Tank Failure is iimminent. The System will Pass Inspection if•Existing Septic Tank k ; .`/ is.Replaced,with.a.conforming Septic Tank as Approved by the Board Of Health. v Sewage Backup or Breakout or High Static Water Level observed.in the Distribution Box is due to broken or obstructed pipe(s).or due to a broken,settled or uneven Distribution Box. The System will pass Inspection if(With Approval of the Board Of Health): - 1 - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Broken pipe(s)replaced Obstruction is removed Distribution Box is levelled or replaced The System required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of The Board of Health): -Broken pipe(s)are replaced - . . -. . Obstruction is removed 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 $S.YSTEM IS NOT FUNCTIONING 11V A MANNER WHICH WILL PROTECT THE PUBLIC`HEALTHAND 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 FUNCTION- ING 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 water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is with atone I 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 and-volatile organic compounds indicates that the well is free from pollution from the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. D)SYSTEM FALLS: 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 coatacted,to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or,cesspool. " �Discharge,or ponding of efluent to(lie 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 clog-ged SAS or cesspool. .. . Liquid depth in cesspool is less than G"below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year DW due to clogged or obstructed pipe(s). Number of times pumped -2- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continucd) Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 Feet of a surface water supply or tributary to a surface water supply. ` Any portion of a'cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 Feet of a private water supply well. Any portion of a cesspool or privy is less than 100 Feet but greater than 50 Feet from a private water supply well with no acceptable water quality analysis. if the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E)1LARGE SYSTEM FANS: The following criteria apply to a large system in addition to the criteria above: The design flow of a system is 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 diinking.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 11 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. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Check if the following have been done: _Pumping information was requested of the owner,occupant,and Board of Health. ' _None of the system components have been pumped for atleast 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. ✓As-built plans have been obtained and examined. Note if they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. - -TAll system components,excluding the Soil Absorption System,have been located on site. ✓The septic tank manholes were uncovered,opened,and the interior of the septic tank was in- spected for condition of baffles or tees,material of construction,dimensions,depth of liquid, /depth of sludge,depth of scum. y 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. -3- b �y M • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST(continued) The facility owner(and occupants, if different from owner)were provided with.information on the proper maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C. .. SYSTEM INFORMATION FLOW CONDITIONS RESID .NT AI Design Flow:-.330..gallons Number of Bedrooms:_ Number of Current Residents: Garbage Grinder: Laundry Connected To System: Seasonal Use:a4Q Water Meter Readings,if v 'I bl Last Date of Occupancy COMMERCIAL JINDUSTRIAi 1% T Type of Establishment: - Design Flow: ; `gallonslday Grease Trap Present:(yes or no) Industrial Waste Holding Tank Present: Non-Sanitary:Waste,Discharged To The Title V System: Water,Meter Readings,.If Available: Last Date of Occupancy: OTHER: Describe) Last Date of Occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System Pumped as part of inspection: If ye ,volu umped: salIons Reason for pumping: vfic7ank/Distribution SYSTEM: Box/Soil Absorption System Single Cesspool Overflow.Cesspool Privy Shared System(If yes,attach previous inspection records,if any) Other(explain). Nf ROXPa A ,AG of l components,date installed(if known)and'sonrce of information: Sewage odors detected when arriving at the site: -4- j y , SUBS.URFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM PART C GENERAL INFORMATION (continued) . SEPTIC TANK: ✓ Depth below grade: Material of Constriction: ✓concrete metal FRP Other (explain) — Dimision s ;•b'X[a ` X �' Sludge Depth: Scum Thickness: Distance from top of sludge to bottom of outlet tee or baffle: dD 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 utlet invert,structural integrity, evide a of leakage, etc 1. ;01 ii GREASE TRAP:—A-11-) 7" � Depth Below Grader Material of Constriction: concrete metal FRP Other (explain) — — — — Dimensions: - Scum Thickness: Distance from top of scum t6top of outlet tee or baffle: Comments: (recommendation for pumping,condition of inletand outlet tees or baffles,.depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,-etc.) TIGHT OR HOLDING TANK:�(� Depth Below Grade: Material of Construction:__concrete_metal—FRP—Other(explain) Dimensions: Capacity: gallons Design Flow: >;allons/day Alarm Level Comments: (condition of inlet tee, condition of alann and float swi(ches. etc.) DISTRIBUTION BOX: Depth of liquid level above outlet invert: Comments: (note if evel and distribution is equal evidence of solids carryover,evidence of leakage in or out f box,etc.) jp ipg- i •PUM -CHAMBER:_; Pump is in woiking order: - z Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) i S o SUBSURFACE SEWAGE DISPOSAL SYSTEM'INSPECTION FORM PART C SYSTEM INFORMATION (continued) SOIL ABSORPTION SYSTEM(SAS): (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,number: Leaching chambers, number:Leaching galleries,number: Leaching trenches,number,length: Leaching fields,number,dimensions: ,Overflow cesspool,number: Comm ts:(note condition of soil,sign of draulic failure level of ponding,condition of vegetation, �,) _ �i CESSPOOLS: Number and configuration: a 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 soilk,signs of hydraulic failure, level of ponding,condition of vegetation, etc.) PRIIVY: .:: Materials of construction: Dimensions: Depth of Solids: Comments: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.) -6- 'SUBSURFACE SEWAGE DISPOSAL�SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to adeast two permanent references, landmarks or benchmarks. Locate all wells within 100 Feet. 1 f 30 ° 1��1 ° f DEPTH TO GROUNDWATER: Depth to groundwater: V Feet Method of Determination or A proxi �/ation: �X�Il9l!' T'eh? 41i h rlo eo u Q , d -7- 1 No. l' Fee v THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: rs PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Application for Digpoar *pe;tem Congtruction Permit Application for a Permit to Construct( )Repair Upgrade( )Abandon( ) El Complete System L'sIndividual Components Location Address or Lot No. L � —, Owner's Name,Address and Tel.No. Assessor's Map/ParcelV y— 4 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 7/-93W Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) /��Qj/� Rooms 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 Certifi- cate of Compliance has been issued by,this B oArd of Health. Signed Date Application Approved by Date - ,-Application Disapproved for,the following reasons Permit No. Date Issued �' No. �°'` +' Fee 7res THE COMMONWEALTH OF MASSACHUSETTS Entered in computer PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Zlpplication for 3kgozar *p!6tem (Construction Permit Application for a Permit toonsttuct( )Repair/Upgrade( )Abandon( ) ❑Complete System LJ Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. `7 3 SQny�1r.�.,u�� �4 Assessor's Map/Parcel cl'11�lal 7- Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 71-93 . 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 t 't Number of sheets Revision Date T Title " Size of Septic Tank Type of S.A.S. 4„ a � Description of Soils — f Nature of Repairs or.Alterations(Answer when applicable) / ����� ROD 0, 6 e,, �OX 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 Certifi- cate of Compliance has been issued by,this Board of Health. Signed Date 9/gl Application Approved by "? Date F p Application Disapproved for the following reasons Permit No. r Date Issued r ----------------------------- �. THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS 60.0certificate of (Compliance THIS IS TO CER�,that the On-site Sewage Disposal System Constructed( )Repaired(//)Upgraded( ) Abandoned( )by `S at i�. 520 1 PZel D61/ i • has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. ated 9 Installer Designer ! f- The issuance of this permit shall-nottp be;o/nstrued as a guarantee that the system'; j ll function as de ed. X �^ Date P! 1 Inspector �/� ��1,��� r'I i tf% - 1' ' t � 1 �J'a✓ � 0 V d �vV V 30✓�, t . No. � —�— �---------------- D Z$ 'd a'� Fee_. THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Mi5pool *p5tem Construction Permit Permission is hereby granted to Construct( )Repair(L_ (Upgrade( )Abando 2- p ( ) System located at ��1J S 4i?ze_% ill yTG9cf/ y 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:Construction must be completed within three years of the date of this t. Date: e Approved ' TOWIM OF BARNSTABLE S' �- LOCATION �� a..� SEWAGE #,?g ` VILLAGE ASSESSOR'S MAP & LOT �0 O \ `INSTALLER'S NAME & PHONE NO ' `{Z 7c, SEPTIC TANK CAPACITY l 0 Q 4, , I . I LEACHING FACILITY:(type) ���• (size),71 X F �NO. OF BEDROOMS -3 PRIVATE /WELL OR PUBLIC WATER /--- BUILDER OR OWNER C' 41,'1Z— o DATE PERMIT ISSUED: " ;% DATE -COMPLIANCE ISSUED: .2 s r VARIANCE GRANTED: Yes 1 4 6 � wKK i l 1 ' ASSESSORS MAP NO: —.,.PARCEL NO.: Nw�R. .... Fizs........... THE COMMONWEALTH OF MASSACHUSETTS OAR® OF HEALTH ..... oF.. -------------------------------------- Appliration for Bispwi al Works Tonotrnrtinn Famit Applicatio s hereby made for a Permit to Construct ( ) or Repair-O 1 an Individual Sewage Disposal S stein at: ta,"/tit,� -V 1)�`E-»�� `� /��®&)/V- /��/�D1 �AR�`7 S 1h/-L L S, ... __................. ••--- ......----.----- ---...----•------------. ......... ........................................................... Location—tiddress � a L Lot W L.�� O v f o �� �Addre Installer ddress UType of Building Size Lot-`_�- �q. feet Dwelling—No. of Bedrooms-._�::_. .........................Expansion Attic ( ) Garbage Grinder ( ) C14 Other—Type of Building 0RP?7A o. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures __________________________________ W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 9 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. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water_-___.--_-______--_-_.-. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water--_-__-_-__..._----:___- t., ------------------------------- ........................................................................................................... ODescription of Soil........C�n&s.a........ ----------------------------------------•---------------------------------------------------.....---•--... x U ---•------------------------•------------....._..--•-------------------------------------•---•------.......------••---------•--•------------------•-................................................... U Nature of Repairs or Alterations—Answer when applicable--___-_✓--�10 ^��-�----`----1--------���7- --------•----- ------------------------•-------------------•---------------------------.............--••---•-••-------------------------------------------------------------------------------....------ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'T"L: y g g p y 5 of the State Sanitary Code—The undersigned furtl era agrees not to place the system in operation until a Certificate of Compliance has been issu d by the board of health. Si ne _ �jj I -&4 ----- ----- --- ------------........._ ....-- --....•--..... Date Application Approved By................. �...... .......................... --•--------- --•--- - e Date Application Disapproved for the following reasons-------------------------------•-----------------------------•--•----------------------------•---•--.....---•-- -•----......•-•---..._.....•----------------------------•---•------------•••---•••-----•••---••---------•--•-----....•-----•----...-------•-----•----------••------•--•------•----------•--•------------ Date PermitNo. .._? Issued....................................................... Date - • '.......--•. &D Fps..... ...... ........... THE COMMONWEALTH OF MASSACHUSETTS ------,--BOARD OF HEALTH ..� ....... ......OF....._? .. .N� .......------------••----------•------ ppliration for Bi_qposa1 Works Tonstrurtion ramit Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal System at: ................................................................--••-•----• ••-•--------••----. Locatia Address r Lot Ao L.n �� lt`a '� Q C .... ... t� U dd s f 4 �••� A 7 Installer Address dType of Building . • Size Loth. . +...._Sq. feet Dwelling-No.'of Bedrooms...__.._ ...........................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Buildin 00 o. of persons............................ Showers ( ) Cafeteria (' Q' Other fixtures ------------------------------------•--•-----••--••----••-------------.:- W Design Flow.............................................gallons per person per'day. Total daily-flow........................._...............-..gallons. WSeptic 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 bo Dying tank ( ) :r x• Date .4 Percolation Test Results Performed b "s aTest Pit No. 1................minutes per inch Depth of I Test Pit_,.................. Depth to ground water_--_--_-:--__________--. Test Pit No. 2................minutes per inch Depth of Test,Pit------.:,:.. ....... Depth to ground water........................ W :........................................................--••...................•- O Description of SoiL.___. ? V ......................................................................................................................................................................................................... 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 IT LE j of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been iss ed by the board of health. �J aCe/ Application Approved By_`__...... ............. .....= .. _<,...= _ .. _.. j Date_. Application Disapproved for the following reasons:........................................................................:...................................... r ------------------------•---------------•----�------�---•-----••------Date--------•-•--- C•^ r Permrt , No. `..- = :2... Issued . ` Date ,t t: THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH'"' c? N.................OF.....r� . � 17` +@4, ............................. Tatif k atr, of toutph aata THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (-- or Repaired, ) by-- ek t ......�r�� ...,.,-� Ins}�ller at has been installed in accordance with the provisions of Tiii j of The State Sanitary Code s described in the application for Disposal Works Construction Permit No� da.ted___.-��__,?.E � :...6:-_-t........... THE ISSUANCE OF THIS CERTIFICATE`SHALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE SYSTEM WILL UNCTION SATISFACTORY. : i DATE ��. ..��.................••--•-•--•.---------------- Inspector ---......:... . ---- THE COMMONWEALTH OF MASSACHUSETT Sy LocAVE BOARD OF HEALTH JSiqi - :;��� .................OF....-2/91A 7294 '-( ................................. ... FEE. -_r.:a•......... Permission is ereby --.....-•-------------•-••----•-------•-------•--............----•----.....--.._......---• ':. to Construct or Repai ( ) Individu Sewage Di posal System 3 - 'T Jtreet 1 , e J as shown on the application for Disposal Works Construction-,-Permif-i-.r`° : �: .,Dated /_.:-: :: �^+ per,. r....-•----..... ------------------------------- `—� 1`, //__ Board of Health DATE...................................................W........---4%'......... FORM 1255 HOBBS & WARR ,1. INC.. PUBLISHERS V� <,Q IWD llo�, v f f _. LOCATION SEWAGE PERMIT NO. VILLAGE - INSTA ll R'S a AME i ADDRESS B UILDER OR OWNER DA;T. E PERMIT I S S U E D D A T E COMPLIANCE ISSUED � ' ( °� � i OX No...... 5 .... � F�s.......5-.............. 0 �) THE COMMONWEALTH OF MASSACHUSETTS YC� BOAR® OF HEALTH 0 ............................. O F........................................------------------................................ Appliration for Disposal Works Tons rnrtinit Frrutit Application is h by m e fpr a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: e . ._-. . ................. �. ...vr.....( ...... -............_. Location-Address or Lot No. .................................... ................... a ..... Ade • .....- ... ner ........... •_ Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms.............................. .. .Expansion Attic ( ) Garbage Grinder ( ) `4 Other—Type T e of Building ............... No. of ersons............................ Showers — Cafeteria Aa YP g ------------- P ( ) ( ) aOther fixtures -----__--------------------------------------------------------------------------------------------------------------------------------------------- W Design Flow...........................................gallons per person per day. Total daily flow__.._.._____.____.._._.__.__._._..______.__.gallons. WSeptic Tank/—Liquid capacitylj6.1d Jq-allons Length................ Width................ Diameter................ Depth................ x Disposal Tre,_pch—. o..................... W�idth.................... Total Length...._____._.. __ Total leaching area....................sq. ft. Seepage Pi ot� . Diameter.AJJ .. -4A�L.. Depth below inlet---� ____ Total leaching area..................sq. ft. Z Other Distribution box Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water------..-----.-.--_---- Gz, Test Pit No. 2................minutes per inch Depth of Test Pit--.---........--.... Depth to ground water........................ a -------- - 0 Description of Soil----. _ ----------------------------------------------------------------------------------------------------------------------------------------------------------•--------------------------------------------------------------------------------------------------------- x W ----•••--•----------------------------•----•----------•----------•-----•--•- ---•-----•----•--••-•------------- -- --- --...----- VNature of Repairs or Iterations—Answer when applicable.- � - Agreement: The undersigned agrees to. install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of L I':L; 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been is ued b fhe boa f health. Signed r ------------------------------------- ------•-----......... Date Application Approved BY-----Zeffollowing ��.............................................................................. ........................................ Date ApplicationDisapproved for reasons................................................................................................................. .........--•--------------•------------------.....---------------•----------•------------I--•----------------•••-••••------•--------••-•------------•-••--•--- ------------------------- Date Permit No..------ --------------- Issued---...............- ...--------• ....................................................... Date No......................... Fxs............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .................................OF........................................................................................... Appliratinn for Disposal Workii Tnnitrurtinn rramt Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: l ...............................................:................................................. .................................................................................................. Location-Address or Lot No. Owner Add Installer Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type T e of Building No. of persons............................ Showers � YP g ---------------------------- P ( ) — Cafeteria ( ) Otherfixtures ------------------------•------•--•-------------•-----•-------•-•-••-•----------••---•-----•-••-------.....---•••---- ------ W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank-Liquid capacity!_-- ?.'.'gallons Length................ Width................ Diameter............_... Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No. '".. Diameter's'.-.A j�?... Depth below inlet... ...... Total leaching area..................sq. ft. Z Other Distribution box Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water.--........--.--........ G14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ --------.--•--- ---------------•---••------•-•---------•-......------.......-----------••---•------......................................................... ODescription of Soil.........'.......................................•-•--•----••-•---••--••----....----------------------------------------------------------•---------•------._...--- x U ---------------•-•-••------•--•---------------•............••----•--•........-------••--......•--•--•.....-------------•••-••--•----------•--••-----••-•------------------......---•........------------ W --•--------•-----------------------•--••---•--------------•--------•---•-•---••--•------•--•-----------•---••----•-••---......----••......-•---•----- -0 U Nature of Repairs or Alterations—Answer when applicable--i, 'e ft ��r?..` �!�S/1 %t�.a•>F% ---------------------- --------•---•----•----------------------------------•--••-••--------•••....-------------•-•-----------•-•---------•••------. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with T P1` the provisions of t'1T t.:.. 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. 1. Signed._!r�f"�./ .C%-r.......................................... .......................... i Date ApplicationApproved By.................................................................................................. Date Application Disapproved for the following reasons----------------•----------------------------------------------•-----------------•-----------------......._...... ....................•---......--•----•--...--------------•---------------....-------------•-•--------•---•-•--•-----•-•--•-••••-•------------•-----•----••-----------•------•---------••-•-----•-•.-•--- Date PermitNo......................................................... Issued...................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... Tntif irab of fauntpliFanr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (Y ) by.................................................................................................................................................................................................... Installer at.................................................................................................................................................................................................... has been installed in accordance with the provisions of TITLE 5 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 FUNCTIng. SATISFACTORY. DATE................................._.. ------•-•---•--•-•----•--- Inspector............._zD(rA_ ........................................ THE COMMONWEALTH OF MASSACHUSETTS t / BOARD OF EALTH �/ .......®F..�.. ...... .... ................... ..... ........ No. ._.F�......... FEE.... .. ........ Disposal Workii Tunotrwtinn amit Permissionis hereby granted----•------1�2 ....... -- ........................................................................................ to Construct ( ) or Repair 4an Individual Sewage Disposal System at No.............. ---•--•-• . ..... ....------��!' - Street as shown on the application for Disposal Works Construction ermit No..................... Dated.......................................... �-------------------------------------•-•-•------------------ ..... ....� DATE...............................OP_.-.2 Z/&......................._..... Board of Health FORM 1255 HOBBS & WARREN, INC., PUBLISHERS