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HomeMy WebLinkAbout0635 WAKEBY ROAD - Health LOT 10 WAKEBY RCP TOWN O'FBAAR�A.I,STABLE LOCATION - SEWAGE VILLAGE ff VV ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO / 77 ���� v�'J SEPTIC TANK CAPACITY LEACHING FACILITY: (type) VC (size) 3 NO. OF BEDROOMS BUILDER OR OWNER PERMITDATE: 2-- COMPLIANCE DATE: c) 1 17 6 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 14&I �5 3 t r i OWN OF BARNSTABLE LCCATIONZ ���y`� [?,el SEWAGE #r&' " 3 r 1 VILLAGE �'I�m?.5 / �lC ASSESSOR'S MAP & LOT29�'� ,6 :? —• INSTALLER- NAME & PHONE NO.ql 'Otlg CiQ n SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (sue) kj) NO. OF BEDROOMS. PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER- LSIO/�,•'�- L?I(f /�� DATE PERMITISSUED: DATE .COLIPLIANCE ISSUED: . '1.'3.�.�7 VARIANCE GRANTED: Yes No �` C6 4 `Q CfA /4� No. w �G + Fee t THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE MASSACHUSETTS Y,Zipprication for �Di5poq;af gpp5temc Cougtruction Vermit Application for a Permit to Construct&ojo"Repair( ) Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components Location Address or Lot No(4W Owner's Name,Address,and Tel.No. Assessor's Map/Parcel 74— t Installer' Name„QcJdreys,a4d T LAA1n0L4q-rAiA (0 Designer's Name,Address and Tel.No. 449Y, 172-2— nv46k,,Oce /"A d Type of Building: Dwelling No.of Bedrooms "3 Lot Size V .3 sq. ft. Garbage Grinder ( ) Other Type of Building ® No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) L/ 0 gpd Design flow provided 33o gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank 1 0670 Type of S.A.S. Description of Soil Nature of R airs or Alterations(Answer when applicable) 1� ' Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issue this Board o Health. �" S ned Date p Application Approved by Date Cp Application Disapproved by: Date for the following reasons Permit No. CD '-0 LM Date Issued No. °__t.: Fee p Entered in computer: THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Ye Application for Mi5po5af"*Vgtem Cow5truction Permit , Application for a Permit to Construct(Nl- Repair C j Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components+ ,Location Address or Lot No pe-4 Owner's Name,Address,and Tel.No, $ el�h� rra60[4a / . Assessor's Map/Parcel ry). rn I I( $ ,Z. 4- � /�Lu/! I fps Installer's Name, ddress,a d Tel.No. t�r,►�Tn �� (o Designer's Name,Address and Tel.No. m 1c .k ��a t,w�- � Ga- f�iuA 17z2- InA scz,4, . S l�o L,d VAS . Type of Building: 2 Dwelling No.of Bedrooms Lot Size V 3z� sq. ft. Garbage Grinder.(_) > Other Type of Building clljl. No.of Persons Showers( M,) Cafeteria( ) Other Fixtures - r Design Flow(min.required) 1 / 0 gpd Design flow provided gpd, Plan Date Number of sheets Revision Date Title Size of Septic Tank I aC oe r,_ ^ Type of S.A.S. !00Cx-e J1^ cz. - Description of Soil � 4 ryry F. Nature of Re airs or Alterations(Answer when applicable) a - ..c-XDCC-11-YN, 14-1 D.�� �n Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of ` Compliance has bee n issued boy this Board o Health. Sed Date to 'gn Application Approved by Date -3- f Application Disapproved by: Date for the following reasons i Permit No. dd.(0 '-0 Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired (,) Upgraded ( ) Abandoned( )by at n VQ R t �. has been constructed in accordance !! _ with the provisions of Title 5 and t e for Disposal System Construction Permit No. Qno b "O t1� dated Y p .. Installer 91 '1 j'19'il'� G Designer #bedrooms Approved design flow '5 3 gpd The issuance of this permit shall not be construed as a guarantee that the system will fun t a ids' g\n d. Date c3 t n i✓ Inspector ` No. l'l Fee 0 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISIQN-BARNSTABLE, MASSACHUSETTS 1=igpogar 6pgttm Conotruction Permit Permission is hereby granted to Construct ( ) Re,air ) Upgrade ( ) Abandon System located at n, Q 1 and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title S and the following local provisions or special conditio \� Provided: Construction must be completed within three years of the;date o this pe" it. Date cam- b ( Approved by --� �i °Ft Town of Barnstable Regulatory Services sexxsreais. 9 MAS& �* Thomas F. Geiler,Director ��FD MA'S A1� Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Designer Certification Form Date:. Designer. Address: 7C E. L.IV&c17/// CIA O2 S On 6 �7/ NA�� LA B U7-& was issued a permit to install a (date) (installer) septic system at ��5 k/�Kday ogo based on a design I.drew* _ (address) _ dated /—/7- o I certify that the septic system referenced above was installed substantially according to-the design. I certify that the septic system referenced above was installed with changes but in accordance with State & Local Regulations. Revision or certified as-built by designer to follow. rjr.- JOHN�v r ( P. IJOYLE.I I I No.33�3g } (Des 'i Signature) 0 SGRN i PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT- CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:Health/Septic/Desiper Certification Form r s Notice: This Form Is To Be Used For the Repair Of Failed Septic Systems Only PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM I, J-hw i° o oYz - ,hereby certify that the engineered plan signed by me dated /- 17-0 6 ,concerning the property located at 35 Gd9K�Gy �20�4-D meets all of the following criteria: • Two soil evaluations excavated for detailed examination(no hand augering)and two percolation tests shall be conducted. • This failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • The bottom of the proposed leaching facility will be located no less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] Please complete the following: A) Top of Ground Surface Elevation(using GIS information) 9D. L B) G.W. Elevation S/ d +adjustment for high G.W. 3, D = 54, 4 DIFFERENCE BETWEEN A and B .3 G SIGNED : G DATE: NOTICE Based upon the above information, a repair permit will be issued for 3 bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans. gASeptic\percexemp.doc '1' No.... 6...� f '� F $...... ........ i THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �(J .............OF...h.1C�C//.1J/. :.4J.L. ................................. Appliratiun for Bhipv ial Works Tonutrnr#inn Prrmit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: RV � / � ( i il.�� /�EJT -/v ' 1� , ��Q ...(�. ., ----- --------------------------------------------------------- - � L cati �s�s lj / �/�� `or t Owne , dr s Installer Address Type of Building Size Lot.. _ /•..Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder.�G "�G� '4 Other—Type e of Building No. of persons.. A-.—.:?YP g -•-------------------------• P ............... Showers ( ) — Cafeteria ( ) A4Other fixtures .._........•--- ----••••-•••-•-•......................---------•--•---•----------•--•----•--•-••-----.............-----•--•......--------••--........ �/� .... '..._......... W Design Flow... .. ...... gallons per person per day. Total daily flow........�� ......................gallons. Gd Septic Tank—Liquid capaci� LVgallons Length................ Width................ Diameter................ De th_....__......_.. W Dis. - a Tench—No. .................... Width.................... Total Length.................... Total leaching area_.0 sq. ft. x �il � ea0m?&.r�[.1.sq. ft. pa e it No...... ............ Diameter.........._..___._.. Depth below inlet..._................ Total leaching ar Z Other Distribution box ( L-)- Dosing tank ( ^)/ �- '-' Percolation Test Results Performed by2`.L��!`^�'4� _Sf-�/2 V..9c'Y�._.. _. Date.......1_.. 1f� ...... minutes per inch Depth o Test Pi _.. .. .�... water../W. a Test Pit No. 1.�: ... p p � �. D to ground .. ............. f3. Test Pit No. 2.��c., ..minutes per inch Depth of Test Pit.................... Depth to ground water�.fJ_ K5--_. x - ----------�--- - ...�_.... .................. ..............•-•-- O Description of Soil ; -------•--•-----•. .... .._.. . r -----------................................. -----------------------------=---------- -..... .. --- W ................................. ...... .............. �� ...... � �zZ,22 ' �-- . ---- VNature of Repairs or Alterations—Answer when applicable..............:__.....____.__..__._..................._........................................ ------------ -....... -....................------•-•--------------................_.............................. -•-------------------- ....... ------------------------ ..--••••••............... -........ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITLi� 5 of the State Sanitary Code Lbythe Th gned further agree no to PI tt tem in operation until a Certificate of Compliance een i uo f Itned.._y �% ' -- -• ----•-•• �.Application Approved BY---------------------•-.. ...... ....... • --.............-• ••-••-•..�. --.-�. ... . ....... ate Application Disapproved for the follow, reasons:...............•------•------...----------------------••-----•-------------=----•--------- •---------- -•------------•---•-•..................•-•-----•--•---•-----•--•••--•------...•-----•----..............--.---••---•••--...•-•----•-•--•-•--•------....-•-••---•---•------•--•----•••..............------. Date PermitNo......................................................... Issued............------•-------......_...................... Date T No........................ THE COMMONWEALTH OF MASSACHUSETTS BOARD _r1_j X��ff �JF I— I JAI ', � ...................OF.......................................................................................... Appliratiou for Uhivasal orko one xnr#ion "amit V Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal sysleme��I-(C-ev Rcj /7) MI) /0 ... 7_777 .... * ............ ........ y ........ . ........ ................... -- ------ i�h ..........;�- ........ ...... Installer Address -----------------------------------*.... ... ------------------------ .... ...... ------------------ ----------------Type of Building Size Lot-----------.................Sq. U Dwelling—No. of Bedrooms............................................Expansion sion ttic Garbage Grinder 44 Other—Type of Building ............................ No. of persons.........._............._... Showers Cafeteria P4 -------------------------------------------------------------------------------------------�o................................. W Design Flow.............................. /,;:;Pa,0_gaIlons per person per day. Total daily flow............................................gallons. 1:4 Septi Tank—Liquid capacity------------gallons Length............... Width..............__ Diameter._._._....__.._. . ---------- 61?iVa�eal_ rench—)(o. ................... Width____________________ Total Length.___..___________._. Total leaching area_;�&.�.sq. ft., Seepage Pit No.................4---Diameter.................... Depth below i*..................... Total leaching area..................sq. f t. Z Other Distribution box Dosi;Cidfik//. : I - ................. Date................. Percolation Test ResAs 15�' Performed by...................................... Test Pit No. ....minutes per inch Depth of Test Pit.................... Depth to ground Test Pit No. 2................minutes per inch Depth of Test Pit..._...._...__.. . Depth to groynd water------------7----------- ....J��, 0 inch - - t ........... ..... .... .70 -9 94 ...�. 4.2Z./_/, ..A_ /. .......................................... 0 Description of Soil............................................ ........................r-, --------------------------- ----------Z.............. ....................................... .................. U .................&.. ............................................................ ..................................................................................................................................... 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 TITLE, 5 of the State Sanitary Code— The u ned further agrees no o la s tem in operation until a Certificate of Compliance en i . ed by the bo f It Si ed.-.... . — Application Approved By.......................... ........ . . .. . ... ... IQ . . ..... ........ ..........4, D e Application Disapproved-for the followi easons:.............................................................................................................. .................. ..................................................................................................................................................................................... Date PermitNo......................................................... IsSue&_..................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARR f_f HEALTH ..........................................OF..................................................................................... Tntifiratr of Toutpliatta I . THIS IrSO�.(ERT5,f Y, That the Individual Sewage Disposal System constructed or Repaired . e Z by_ C?........................................................................................................................ . ........................................... Installer at.................LvA------#0..........AV4.14 . ........fW. ......... . ........................................ has been installed in accordance with-th7provisions A, TIT :-State anitary Code as described in the application for Disposal Works Construction Permit N6......................................... dated_....._.._...___.._.....___..__............._... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................. Inspector..................................................................................... f-fAj i sN�_e r au 5 THE COMMONWEALTH OF MASSACHUSETTS 11 A (fv kA'05 1� S-TA OtA BOARD? OF HEA-LTH 1p —fit J 0S AV-%c c 5 N62 OF.................................................................4.N 0 WX F'r Disposal Workii. Tonotration rrmit CA O-CA. Permission is hereby granted....................Q......�_-. .............................................................................. to Construe't X or Repair an Individual Sewage Disposal System � .. .......... I), -------- at No.......................................Lou A... 1.0 r.4 to. ,Street --------------------------- as shown on the application for Disposal Works Construction Permit N Dated...-E- ................................ .. . .._.. .. .................. oa DATE...................... ................................... FORM 1255 A. M. SULKIN. INC.. BOSTON 0 M <jTj�hc r ��Fk.4�E unr�T 2 o e� yob , J � o �r� 31 / + F . /IV PTG Z . 0 2- 0 Y 4 qq �' ,S v ' F- v F✓T°t� 1505�78A MKS yo ;�I Z,' Z© 7- b y PH' ILIP �Q�°��O N -� WEInIc„�,�; "S O N AL 9.3 V" LEGEND R EXISTING SPOT ELEVATION OxO CERTIFIED PLOT PLAN EXISTING CONTOUR 0 - -- t� OF4 ` �s� ' FINISHED SPOT ELEVATION �� O T P �'� «a % �`to•�ty R�� r M % FINISHED CONTOUR 0 �. �i� _Tc'SU /-� M/L.LS I N APPROVED BOARD OF I HEALTH No i67 s A it klS I AS � CIA . . DATE + " DATE AGENT A �E ? SCALE o / "— 4 DATE LDREDGE ENGINEERING CO. INC CLIENT I CERTIFY THAT THE PROPOSED 'REGISTER E REGISTERED JOB NO.9M BUILDING SHOWN ON THIS PLAN 1 CIVIL LAND DR.BY= CONFORMS TO THE ZONING LAWS ENGINEER SURVEYOR OF BARNSTAB E , MAS 7.12 MAIN STREET CH. By: HYANN I S :MASS Z SHEET:' OF DATE REG. LAND SURVEYOR 20 /aT. M/N 1lOTE /F E/TNER THE SEPTIC TAN.#< OR /EACs/InrG P/T ARE MORE- THAN /2"BEL0PV /O FT MIN rRAOEl f� 24'O/A14E7.4.rK C0/VCRE7,A= COVER B.E BROUGHT To 4gMAOE.64/✓ .EXTRA CONCRCTE 9 PVG P/PE + 4 V Y CA ST /RO/V C O{/ER S, 4 L L- 3E US F1� M/N. P/TCH f --- EL . / 2-.Q COVERS X8 0 PER /N DR/✓EN/A y a • / I �•0 2' M/N. CONC,QE'TE j� • 4R.loE CO YER j ,,— CLEAN .SANG "_•• LQ[J/O LEVEL" a j. { 4"DIA. r j _ SCNE046 40 '. Z LAYER 1 p c. PioE CA 1Ga, y o a o -�AQ Or %v�P&�r r-�: SEf'T/C TANK oisT s t • . . . • • • • �� * WASHED STt�NE ; BOX v v e • • $ • • ♦ • • • . e� / ' M :.;:• , o • • •, o�PTi+I • • I • o yV.4SX,ED STONE . ;7. _ :: ► D I,• • • • •♦ 1 Leo • /�.7 X 2�5- 377 b o • I I • • • . • I • a P `' PRECAST$f.E7GE INYCefT e`LEt/A7'ION.S R/7 GA.PrA.e r�y �90 GA4 /vay .. o • • • •- ♦ • • • • ' s a P/T OR EQU/1/ -, - . p e a EL 92o P /NYERT AT BUILDINGS FT. 3 r_ 6 FT D/ANL. LET. SEOTYC .T.4/VK ��fT, _ CZ FT D/�!91►9 '':14 C�S1r�ET�iBI/L.4TION� . ' OUTLET SEPTIC T'4jq-�C _ •[ ..FT ,. /INLET D/STR/BUj/ON BOX: 6-9 FT OROuNt�:J ITERTi4BLE 011 LETD/STR/ `. SECT/ON 4F INLET LEACHI/ "f'rTFT "° . SFI�V�IGE 'OISPO�SA L SYS�'EM r LEACN/NG. P/T f: , _TABULATID/Y DESlG/Y G'ft/TERlA JCA�.LEE. R FT NUMBER OF+BEORO'OMS 3 F `' • : ' • . D/MENS/4N� C, ua' F�• p� ni GAR8,4GE 0/SPOSAL UNIT No.n/E SOIL- LOG TOTAL E�TlMt47"EO FLOt�V 3 3 u G.4L.�DAY " DSO/L TEST / . $OIL TEST ,2 SO/Ll TEST NlIMSER OF LEACHING. PITS _I !'FLLrK 99 0 �^-EL&rY, ;DATE OF SO/L TEST /'�!41'�G , S/DE L�`ACHING PER P/T /Sa,7 SQ. Rj I� i G.W-- McKEs�N 6oTTOM Lr-sACH/NG PE1t'pIT/!3 1 U- 3 RESULTS Jet//TNESSED. BY Sc1. FT. i aim V- PE1vcaxAT/ON MATE#/ L�5S'M/IVII/N4,H S u35oiL TOTAL LEACH//YG AREA � SQ. :iT. PJENCOLAT/ON RATE�2 rM'�"VMlN.1/JV�N � RESERVE LE.4G'.rllNG AREA _SQ. FT 2-0. tN �F hfgs J. "' '' � ` �3, .. VE L^ s, � -Tz 5 Tyot/S M/L.L.S . o=:r s 14'ILIP qq WE10BERG E, vn r f "7jt ' 4- % L L . EL DREDG&E,/Va1Af ,V1h•, U C4 PVC. No. 366 /LMAINT � 7 D 7 MS ti a r ..;,., " o— G` w�'`4 q� ' E i., (r� NO GROUND yYi4TER ENCOIJNTl��2E'O Ci/EN Y f .OLt�t iv f9. DATE ! Z 3/ 6 � ��--` -•ems° GRO UNQ lt/�TER'A7" EL.Et� /t7 Z.pR 2 -�L�c%�� L(/�tG.�2,{r- ����i ✓l�' .. �OB NO. �_ SHEBT_ C 3 �7 LO�C TT' I�oN � S E �QL7 PERMIT N0. VILLAGE INSTA LLER'S� ME & ADDRESS 6UI'LDER OR -*WM,W- Le DATE PERMIT. ISS WE D y DATE COMPLIANCE ISSUED � P � � 4 ' �� .� !� A �; � ' �� ,►� ' i ��--. � Z,��:��' �J_ '/lam cam°" LOCL.TION 5EW&C-4E PERMIT MO. IW5TALLER5 1 66KAE ADDRESS BUILDER 5 Q &MF- ADDRESS i - `lam - - DATE PERNA T 15SUED DATE COMPLI W-ACE ISSUED : =J �� t � � 1 I A' C% No.......;O .... FRs.. ..�� THE COMMONWEALTH OF MASSACHUSETTS OAR® HEALTH ............ _ ...OF........ Appliratiun -fur R,ipuuttl Worbi Cnunutrurtiun Vrruiit Application is herebymade for a Permit to Construct ( ) or Repair ( ) an Individual Sewage .Disposal System at: i ----- ---------- ----- Loc n- ddress or Lot 'o. �L.... . Uc.v/ ------ ---------- p, Owner Address W ' • ........... ................................................ Instal er Address UType of Building Size Lot l.G.ZX`---------- feet Dwelling—No. of Bedrooms____________________________________________Expansion Attic ( ) Garbage Grinder Other—Type of Building ____________________________ No. of persons..._.______________________ Showers ( ) — Cafeteria ( ) dOther fixtures ----------------------------------------------------------------------------------------------------------------------------------------------------- W Design Flow........J.`. f__J.........................gallons per person per day. Total daily flow...../.--_--_______________._.._....gallons. WSeptic Tank—Liquid capacityA C gallons Length---------------- Width_---...-------- Diameter................ Depth.--.___------ x Disposal Trench—No/........ Widt}}i------- _ - Total Length.................... Total leaching area--------------------sq. ft. � PSeepage Pit No._________/_....._.. Diameter...1--UUG'3:e th below inlet.................... Total leacl t 1------------------sq. ft. z Other Distribution box ( ) Dosing tank ( ), d , �/" -7 �Q aPercolation Test Results Performed by---------------------------------------------- ........................... Date........................................ a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water..-._-_-._.-__.__._.. - 44 Test Pit No. 2................minutes pe inch Depth of Test Pit-------_............ Depth to ground water__.__...___.___._____... 19 ......!_. r----- ------------------- � - •••. O Descri of Soil--------���- - - --- =-._.f'1--.`+ --- �-�"�--y---- - ----- - -----{----------------------------------------------- W Pr--0;f;'�- - e---/---- 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 Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b issued by the bo =o . h. �Signe . � ••--- J // �l1...-...... . /' Date Application Approved BY - ......_.._ ... __ �� `��� Date Application Disapproved for the following reasons--------------------------------------------------------------=----------------------------------------------•--- ---••-•-•----•---•-----••-•----••••••-•-••-----------------•-----------••••••----•--•----•-•••••-•-------...••--•••------•-••---•-••••---•••-----••-•---------•--•--------------...--•---------......... Date PermitNo.......................................................... Issued....................................................... Date Nu..---.. .U1/J.... Fins...`d............... THE COMMONWEALTH OF MASSACHUSETTS BOARD O HEALTH r6p�. ...OF----- .. . .. ........................`--- AppfirFation -for Biiipao al Workii Tonmrurtinaa Prruait ; Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Dispo-sal System at: (? /. 4) 1��,�}/!�-z �t/ '1z 1 ............................. ....................................... ...................... ...•--•---•-•----•-----•••••••----••--•••--•---•---•-----....-•----..........._......------...... Location-Address _ or Lot No. / ��zf( � f ''jiS I�= FCC+/ ✓ r�_.._SCl W �JJ Owner' Address • •................a' /J yr � c-1 . ..................... . .......... ....................•......------.. •--<`�.y Installer Address UType of Building Size Lot,_�U- G_U---------Sq. feet Dwelling—No. of Bedrooms------------ ------------------------------Expansion Attic ( ) Garbage Grinder (1 6) aOther—Type of Building ............................ No. of persons_.._-__-___-•_____-____-_-__ Showers ( ) — Cafeteria ( ) G, Other fixtures ----------------------------- W Design Flow...._._.._'---------------------------------gallons per person per day. Total daily flow..... .........................._.gallons. WSeptic Tank—Liquid capacityf`I'�_(`gallons Length---------------- Width......---------- Diameter--.------------- Depth.-_______--_--- x Disposal Trench—No--------------------- Width___-_______--)___. Total Length------------_----- Total leaching area--------------------sq. ft. Seepage Pit No._________/._ �f��G�t ...__. Diameter__________ _______ Depth below inlet.................... Total leach' a��,1sq. ft. Z Other Distribution box ( ) Dosing tank ( ) ��- — y-/— 7G ` /.` ................... 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.______J__�--.•__-___- Depth to ground water__.__-___-______-___.__. Descri t of Soil.-______ .'__�.. ._^__._ f -1 2_-------_........... U -------------- WIJ- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 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 Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has /be'erpissued by thhe�bo -r of he Ith. -- --- Date Application Approved By- f ����<;� - -x ---------------- -- Date Application Disapproved for the following reasons---------------------------- ------------------------------------------------------------------------ ...--••--•--••--•--------•--•-------------------------------------------------------------------------------------------------------------------------------- -----------------------._.......... Date PermitNo.....................................---•-•------------- Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ....... ....✓ 11-4'Z...........OF........ ,i J ll ':.1..� ,fir:..n.-....................................` Trrtifiratr of TlImphaurr THIS IS TO CERTIFY That the In ii,dual Sewage Disposal System constructed (,/ r Repaired by t /- �/ "le yt l - - ----- ( ) .............................................................................................. Installer at T1 � has been installed in accordance with the provisions of A> c XI of Th State Sanitary Code as described in the application for Disposal Works Construction Permit No. ____p _/l ........... dated-._-___f,_,ta. /_z6............. THE ISSUANCE OF THIS CERTIRCATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION S ISFACTORY. DATE................ ---------- /---- Inspector--�••.. - ............................ THE COMMONWEALTH OF MASSA TTS BOARD O HEALTH J , No......°� .... ..... FEE.,/ eQ----------- Bispaiittl a1rk Ian traarti�a$t rranit Permission, i�.lrereby granted. �'--------=- -- ' ,� '' '' '- r !� ------- to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at No f=2 _ / L................................... �t 1 �,t1 i I�r +S- ' S%%f T/ -------------.. Street as shown on the application for Disposal Works Construction P ____. n._ Dated__ '.- __o-�..�C,__._..... _ Board of Health w 7 DATE// ...fi/::.._tla� !-- !--� / - / �,_ FORM iZ55 Hd' 3S & WARREN. INC.. 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