HomeMy WebLinkAbout0177 THISTLE DRIVE - Health 177 THISTLE DRIVE, MARSTONS MILLS
A= 149 130.035
I
F-VI
C-. P ION# SEWAGE PERMIT NO.
LAGE
I N S T A LLER'S NAME i ADDRESS
aka e G- g
I U I L D E R OR OWNER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED Ile)
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CERTIFIED SEPTIC SYSTEM REPORT
McElvno
J U N ? Q 1996
LOCATION HEALTH f '
TOWN OF C° {
'�n 177 THISTLE DR.
V v j -fvl C MA 02632
MAP 149 PARCEL 130.035 LOT 3
PREPARED FOR
SFTIER r.AMOM MAP t
MR. & MRS .. ROBERT W . BRIGGS
P .O . BOX. 549 ��
FAYETTEVILLE, NC 28302
BUYER
MR. & MRS . PETER J . SIELICKI
74 BROOK LANE
MOUNTAINTOP, PA 18707
PREPARED BY
HILLIARD HILLER
P .O . BOX 250
CENTERVILLE... MA 0.2632
508-778-1472 :
I
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Department of
Environmental Protection
WNNam F..Weld Trudy Coze
s.uwsry
Gomm David
Argeo Paul calluccl ���3�ar
tt GOMM
SUBS URFACE SEWAGE,DISPOSAL SYSTEM INSPECTION FORM
PART A.
CERTIFICATION
Property Address: /77 TA15% Z VK G,eD�T�2!/lGL•c Address of Owner, IZ/h 10114eT e"'
(If,different)
Date of Impeodow 61or PO /3 6X 4/
Name of Inspector. /-I/LG<fl2o
Company Name.Address and.Telephone.Number. pp lgox a S� L/�//� 77',C a/GG,C ,rjC
CEItTIFICATTON STATEMENT
that I have personally ins the sewage disposal system at.this address and that the information reported below is.true, accurate
I certify perso petted
and complete so of the time of inspection. The:inspection.was.performed,based on- my training and experience in the pioper function and
Vailinte"ance of on site:sewage disposal systems. The system:
_ Passes
_ Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
Fail&
Inapeotoz+s SiQnatwtt. /f��%�/'Y_�',��C�/r/ Date: 4/1 y/ fe
The System%gpe=shan submit a copy of this inspection report to the.Approving Authority within,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 office of the Department of Environmental.Protection.
Mwcrigmsl-should.be sent to the system,owner,and copies,.sent.to the buyer;.if.applicable and.the approving authority.
INBPWrION SUMMARY;
Al SY9r=PASSES.
I.ba e:not 5oaad any,information which.indicates that the system violates.any of the failure:criteria-an defined.in.310 CMR,LU03,.
Azw failn>a criteria not evaluated are indicated.below.
BY SYSTEK'CONDTTIONALLY:PASSES:
One-or.more system.components need,to be:replaced or-repaired: The=system,.upon.completion,of the replacement.or repair.;pessmu
iaspstticn:
Iadi�ats yn;-n0.ornot determined.(Y;N,or ND): Describe basis,of determination,in.all:instances. If"not,determined',-ezplain:.why sot)
The septic tank is metal..cracked:.struminny unsound; shows..substantial'infiltration or exfiltration,:or tank:failwe.is.
imminent. The-system will pass:inspection:if_the-existing..septic tank-is ieplaced with.a.Fonforming septic tank as•spprcved
by-the!Boar&cf Health.
(revised 11/111M.) 1.
OneeWbttarStreet s Boston;.Massachusettsc02108, ' e FAX,(61.7)SW1049 TeePhonr(617)292-5500:
.prvmedon-RecvekdPaoe-. P/1�4. ...�: �S /�•
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM.
PART A
CERTIFICATION(oontinued)
Property Address: 177 7&1,e r&1, 0,2
Owner. ,y/,a 0�a e/Z r G/
Date of Inspection Gy{
DI SYSTEM FAILS-
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 Om—c the
failure.
Backup of sewage into facility or system component due to an overloaded or clogged SAS or,cesspool.,:
Dimbarge.or ponding.of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool..
Static liquid level in the distribution,box above-outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth.in cesspool is less than 6''below invert or available volume is less than 1,12 day flow.
Required pumping.more than 4 times. in the last year NOT due to clogged or obstructed pipe
Number of times pumped
Any portion of the-Soil Absorption Svstem. cesspool or privy is below the high groundwater elevation.
Any portion.of a cesspool or pri`y is within 100 feet of a surface water supply or tributary to a surface water supply..
_ or privy is within a Zone 1..of-a.public well.
Any portion of s cesspool
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 ham.been.analyzed to be acceptable. attach,copy of.well.water analysis for
eoliform,bacteria,volatile:organic,compounds, ammonia.nitrogen and.nitrate nitrogen.
El LARGE SYSTEW FAILS:
The fallowing:criteria,apply to large systems.:in addition to:-the:criteria-above:
The gstem serves a-facility-with.a.design.flow of 10,000 gpd or.-greater(Large System) and the system.is a.significant threatAc public
baaltb and safety sod-the environment because:one or more of'the-following conditiors u. exist:-
the system. 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 M of a public-
-saw'.supply.well)
'The owner or eperatar of say.such system.shall bring the system-and facility into full compliance with.the groundwater treatment program.
.of."314 C3G,,5.00 and,6.00. Please-consult the-local.regional.office:of the Depaxtmeat forfurther information:
(revised.11'/03/9S): _ 3
r;
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: G'e
Owner. 1-t1,r1 �v G✓ /��/cCs
Date of-Inspection: ✓
'Cbeek if the following have been done:
✓'Pumping information was requested of the owner, occupant. and Board of Health.
L None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
during that period. Large volumes of water have not been introduced.into the system recently or as part of this inspection.
jAs built plans have been obtained and examined. Note if they are not available with N/A.
_L 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 sighs of breakout.
✓All system components,excluding the Soil Absorption System, have been located on the site.
vThe septic tank manholes were uncovered opened, and the interior of the septic tank was inspected for condition of baffies or
tees,material of construction, dimensions, depth.of liquid, depth of sludge, depth of scum.
I/The site and locationof the Soil Absorption System on the site has been determined based on®sting information or
approximated by non-intrusive methods.
v The facility owner(and occupants,if different from owner) were provided with.information on the proper maintenance of Sub.
Surface Disposal System.
(revised, 11/03/95) 4
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: !7 7 Tfrj s/�G/� a e G 4
Owner.
Date of Inspection:
FLOW CONDITIONS
RZSMMgTIAL•-.
Design flow: o na
Number of bedrooms: 3
Number of argent residents: 3
Garbage grinder(yes or no):_&�
Laundry ooanscted to system(yes or no): yxs .
Seasonal use(yes or no): Na /S(. �flG /cf>5'-
Water meter readings,if available: /9�15
Last date of oxnpancy: /9'esze�r4-Y
COMMERCIAL/INDUSTRIAI—
Tynw of establishment:
Design flow-pllons/day
Grease trap present:(yea 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 acarpancy:
OTHEII:(Describe)
Iast date of o=pancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as part of inspection: (yes or no)-YSS
If yes,volume pumped: mom
Reason for pumping SOL/GCS /G
TYPE OF SYSTEM
1,-'Sephe tankMistribution bca/soil absorption system
Single ossepool.
Owrfloow as spool.
Privy
Shared system(yes or-no) (if yes, attach previous inspection records, if any)
Other(erplain)
APPROmIATE AGE of all,components,date installed(if known)and source of information: llalL./C //
Sewage odors detected when arriving at the site: (yes or no
(revised 11/03/95) 6'
e _
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 177 711/S72—C ,pe
Owner. .q O8 r L✓
Dale of Inspection: CA9C .
SEPTIC TANK y
(locate on site plan)
Depth below grade:
Material of construction: "Concrete_metal_FRP—other(explain)
Dimansionx: "x
Sludge depth; O „
Distance from top of sludge to bottom of outlet tee or baffle:' 3
SC=+him: 02
Distance from top of antra to top of outlet.tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.) 7,%e-xr %�l-S �k 1 �t�/J T iT UGC .Co 7Z> .e
GREASE TRAP:,
(locate an site plan)
Depth below grade:
Material,of construction:_concrete_metal_FRP other explain)
Dimensions:
Scum:thiekaessr
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of antra to bottom of outlet tee or baffle:
Comments:
(recommsadation for pumping,condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage,etc..)
(revised 11/03/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner. �1/,.7 �O/�/�T G✓. /.C,Q�G�
Date of Inspection:
TIGHT OR HOLDING TANK-1
ate(loc an site pia) r.
Depth below grede:
Material of const nXtion: _oonc:ete_metal_FRP_other(ezplain)
Dimensions:
Capacity gallons
Design!]ow: gallons/day
Alarm level:
Comments:
(coaditica of islet tee,condition of alarm and.float switches,etc.)
DISTRIBUTION BOX. !/
(locate on site plan)
Depth of liquid level.above outlet invert:
Comments: �� ��
(nob if level and distr*ation is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
PUMP CHAMBSB:�
(locate an she plea)
Pmaps in.wazlang,arder(yes or no) .
camomeats:
(lots cmubtum of pump chamber,condition of pumps and appurtenances, etc.)
(revised 11/03/95') 7,.
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Addr— l 77 Tdf/STG E ,O/1, G r/l�.�vl LGF_
Owner. h �QoB,�2r Date of Inspection—
SOIL ABSORPTION SYSTEM (SAS):—(._-
(bate an site plan,if pomble;excavation not required,but may be approximated by non-intrusive methods)
If not dstsrmined to be present,explain:
Type:
lssehing Pate number:
chambers, number:_
kwhiag Galleries, number:
lstc)" trenches, number,length:
1-chin fields, number, dimensions:
aw llow cesspool, number:
Comments:(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation etc.) -T//� �o,0'/T Ll�S
0�4'd,�D .av� r c�i•9 S FvL�- .4iG u T T4" 7;AI e'
(locate,an site plan)
Number and configuration:
Depth•top of liquid to inlet invert:
Depth of solids.layer:
Depth of swm layer.
Dimmi-cof cesspool:
Material of comstavdion
Indiatioa of watmdwater:
bdow(cesspool must be pumped as part-of inspection)
Comments:(note condition of soil,signs of hydraulic failure, level of ponding,.condition of vegetation,.etc.)
PRIVY:
(bate bn site plan)
Materials of construction:
Depth of saws: Dimensions:
Commantr(note condition of soil,signs of hydraulic failure; level of ponding,condition of vegetation; etc.)
(revised:11/03195) g
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
RopeM.Addrew /77
Owner. T /
Date of Inspection:
SZ=B OF SEWAGE DISPOSAL SYSTEM:
inc] ties to at lwst two permanent references landmarks or benchmarks
locate aIl walls within 100,
FRo,vt iG�f �,
DEPTH 70 M01MWATEIt
Depth to pa®dwatar //' feet
zwthod.of&twn"atim or apprcaimation: �A,Qtl5 lflq�/' l/S Si✓rwS TH/ S/T fIT �'/d ys�Ti�.v
6p > T ftC` Cia776b+, �A %A,-- �1 r 1 S R� Og.tc'.a. Tfy/i G�SS£.C✓{e! G.��s7",t%I ?i9�y'c"✓£ C7'c�,t�.[
/�i57 O.PAt✓i�� 5/yl/c✓3 Ti�2 c.. Term !/t'.�Ly£ /9T /LG�!/�9T/ � 38. 7-
9-
.
X-
TOWNfOF BARNSTABLE
-P SEWAGE # 3
LG^_AiTON � � l �I
VILLAGE SESSOR'S MAP OT d 00s
5 LER'S NAME&PHONE NO. ° 2/w
p /
SEPTIC ANK CAPACITY'
LEACHING FACELrrY: (type) (size) Jode 4
NO.OF BEDROOMS °9C7�
BUILDER OR OWNER lJ
PERMITDATE: 7— 1.. —�7 COMPLIANCE DATE:
Separation Distance Between the: 4
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility If an wells exist
P Y g tY ( Y P
on site or within 200 feet of leaching facility) /�/� Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
t
f3 -- � -�
No. (a'3Y �. R, Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
01ppYication for loizpooal *potent Construction Permit
Application is hereby made for a Permit to Construct( )or Repair( )an On-site Sewage Disposal System at:
Location Address or Lot No Ow r' TNe,Address and Tel.No.
/ �,'`
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
TC Mci i2 rw
`7 5-
Type of Building:
Dwelling No.of Bedrooms 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
Description of Soil
Nature of Repairs or Alterati ns Answer when applicable) lo DG
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 ofi the of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issuedby thi Board of th. q
Signed � Date
Application Approved by Date
Application Disapproved for the following reasons
Permit No. 96 3 7 Date Issued -7 4 6
�1 r , a,
126
No. /4 '7' 3 xl O
r. Fee
- THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
2pplicatton for Mtgolal *p5tem Construction Permit
r
Application is hereby made for a Permit to Construct( )or Repair( ).an On-site Sewage Disposal System at:
Location Address or Lot No, �ow r' N e,Address and Tel.No.
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
.tl R 1 w e
Type of Building:
Dwelling No.of Bedrooms Gdbage Grinder( )
! Other Type of Building ✓m persons.. Showers( ) Cafeteria( )
Other Fixtures ' � A
Design Flow gallons per day. Calculated daily flow gallons. f j
Plan Date Number of sheets Revision Date j
Title f 1
Description of Soil
' Nature of Repairs or Alteratioo�ns,(Answer when applicable)
i
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 o itle of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issue by thi B d:Z!th. q
Signed Date 7
Application Approved by Date .7 SS
Application Disapproved for the following reasons
Permit No. 6 Date Issued 7
i -------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THI&IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/replaced 41—on
by r Fr-" M vc-v✓1 Installer
at has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction t No. dated 7
Date '-'i? ` l, <7 Gam. Inspector
/ 0..I� L
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE TH E SYS-
TENI WILL FUNCTION SATISFACTORY.
— � 6 — — -------------------------
J `f 2 FeeTHE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
mfgponl potetn Conotructton Permit
Permission is hereby granted to A
to construct )repair( an On-site Sewage System located at No.# `7
Street
and as described in the above Application for Disposal System Construction Permit. 9 G-a y"7
No. Date
The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions.
All construction must be completed within three years of the date below.
Date: 7 _ - 9� Approved by h/
Board of Health
` 1
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS)
I, hereby certify that the application for disposal works
construction permit signed by me dated - �-C — �� , concerning the
property located at / "7 7 �� �� meets all of the
following criteria:
1
• There are no wetlands within 300 feet of the proposed septic system
4
• There are no private wells within 150 feet of the proposed septic system
• The observed groundwater table is 14 feet or greater below the bottom of the leaching facility
• There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
SIGNED: DATE: - l
LICENSED SEPTIC W M INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
[Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
I'
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C-1 :
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TOWN OF BARNSTABLE
LOCATION 27 'rl-11514,e" SEWAGE#
VILLAGE ASSESSOR'S MAP&LOT
IAI T�4L- 8 NAME&PHONE NO. A /.11/ X t 7J J'-1 z17 2-
SEPTIC TANK CAPACITY 6�L
LEACHING FACII.ITY: (type) �/1� (size) Grp
NO.OF BEDROOMS 3
MMOM OR OWNER
PERMUDATE: //Zd eZO COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and 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 / 7-4�`
•,
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i
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ii'Rovt �3 G �
S'
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N
THE COMMONWEALTH.OF MASSACHUSETTS
BOARD OF HEALTH
C?-+.r- ........ OF...........
Appliration for Diupuual Vorkg Tomitrurtiun Vamit
A !cation is hereby made for a Permit to Construct ( ✓) or Repair ( ) an Individual Sewage Disposal
Val: � � °- •� ..............
l,�cation-Address ............................................ Lot No.
Owner Address
a .................... ... .... ------•------------.._.......-----•---••---•---...........................................• -•
Installer (/ Address
d Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder It`u)
'4 Other—T e of Building No. of persons............................ Showers — Cafeteria
aOther fixtures .-----------•-- ---------------------------------
W Design Flow.................... <:..__
...........gallons per person per day. Total daily flow........................ ..._gallons.
WSeptic Tank—Liquid capacityRM.gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No..................... Width........;.__.._.... Total Length.....................Total leaching area.....-._...........sq. ft.
3 Seepage Pit No.__....._..I........ Diameter............... Depth below inlet........&....... Total leaching area..�®Q..sq. ft.
Z Other Distribution box Dosin tank ( )
Percolation Test Results Performed by. (R_ _.._ .. .....As. ..&ate........1 -f'.t/ �®
Test Pit No. 1.....7L_.minutes per inch Depth of Test Pit.......' ,..__ Depth to ground water.........
(s, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a --------------------------------------------------------------------------------------••--------•--.........................................................
0 Description of Soil......................... - ------------ -----••---•-----------------------------------------------------------------------------•-------------
x
w
------------------- ..-----•-•-----------•-------------•--------------------•-•--------------------------•---••------------•----------------------•--------------------------------•----------...
V 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 TL 1 TME 5 of the State Sanitary Code—The undersigned further agrees of to ace tl system in
operation until a Certificate of Compliance has been issue he board Ahealth.
i
Signed-- .......... -----j----------- -------------------------- ------ ....... ... f.._
ate
Application Approved By........ ---.✓��.... ...................-.... --.-1/�?.. .. .11.------------.
Date
Application Disapproved for the following reasons-----------------------------------------------------•--•------•------------------------•---•-------------•--•---
....--•----------------------•--•----......------------.......------------••-•----------.....-------•---------------------------------•---------------•-------------------...----•----------•-----------
Date
PermitNo......................................................... Issued.......................................................
Date
n
a ~
N .....- B Fizs.J.. .................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH'
�r ...................OF.......... ,,,.............................................................
Allp ira Lion for DiipugFal Work/,i TonstrurtiunR, .erani#
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage.Disposal
System at:
................__.-----............ .. .---•-__.......--•--••. ...... ......._... ..........----- T .._..: ..........................
/� _Location•Address or Lot No.
•t�c v�.en���.:vC•-•...L::::rj.e _tieti ............................... ......... ...................... ....•---•-•--•--..............................
Owner , .
Installer Address
Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms................................ .....Expansion Attic ( ) Garbage Grinder ( )
�7 -
p-, Other—Type of Building ............................ No. of persons............................ Showers ( ) Cafeteria ( )
Q' Other fixture
----------------------------------------------------------------------------------------W Design Flow................... --_-gallons per person per day. Total daily flow................... L_�O......gallons.
WSeptic Tank—Liquid'capacity. �(7d_.gallons Length................ Width................ Diameter---------------- Depth................
x Disposal Trench—No.................... Width........I....._..... Total Length.................... Total leaching area ........sq. ft.
Seepage Pit No........... --------- Diameter----------- -- 9 P ,•.. ---... g ��...sq. ft.
. ._ Depth below inlet.__ _�._. Total leaching area._._._. q..sq.
Other Distribution box ( Dosing tank ( ) I i
`'" Percolation Test Results Performed b ... ���.�. .�:; ... I...... { A# *J C"- Date........'..`..I ............
4 Test Pit No. I.....�..minutes per inch Depth of Test Pit......t ,..... Depth to ground water.._.............__..
fi Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Q+' •---•--•---•-----•----•-••••-•-----••-----•--------••...........................................................•---•-•----.....----.._.........•••-•-..----
0 Description of Soil........................!
x -----••-•-----------------------------•-------------------•---------------.---.-------------------------------
............
r` ':.� 1.&Aft?...-- � (S
U .............................................. >
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 TIT1Z 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has/been issuedrbyfthe board of health. L
................ C. . �.
Date
Application Approved By...,.. '� `'-> -•-G......... ..... 1 ... ' ���1 '��
..----- ----•••>- -------------------
Date
Application Disapproved for the following reasons:..............................................................................................................
........-••-•.................•--------•--•-----•-------•----................--------••--....------•••---------•----•--••-••--------- ...............................................----••---_-------
Date
PermitNo......................................................... Issued-.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
,1-.....�t��
..............'.�-�...................O F............... .......-............................................................
Trrtif iratr of Toutplitturr
THIS IS7 ' C,BRTIFY Th�he I 'vid Sewage Disposal System constructed ( ) or Repaired ( )
•
Installer f/
at.....---- -=�---------'•----��.........--�•-•--•------... =---��Z 'i .................................................................................
has been installed in accordance with the provisions of Tj_LP, 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No._(�0._ ._6'_ '&............. dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION /SATISFACTORY.
DATE 1 /4., .'........... Inspector.... f ------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF..... .. HEALTH
Nd v� . GS r, OF..... p-=-."�-./-- -------------------------�............ FE .�'...-
E..
Permission is ereby granted-------------- -------....................................... . �y........._f1't.�iv,
to Construct�(7�or Repaid( ) an, Individual'-Sewage Disposal ystem
---------•-•----•-----------------•-----•---• .. --•--
Street
as shown on the application for Disposal Works Constructiorr-Nrmit No..................... Dated..........................................
1,41, ,, Board of Health
DATE--- -•••••-----••..•-•-•----------•--••--•-•--•--------••-•---••...............
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