HomeMy WebLinkAbout0151 WALNUT STREET (M.MILLS) - Health -- 1 T WALNUT ST I-e `- - -
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APPROVED THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH ao,:�
.� 4' OWN OF BARNSTABLE
.�ppliration for Dhip Sal Wnrk,i C owitrurttnn ramit
Application is hereby made for a Permit to Construct ( ) or Repair (L,<an Individual Sewage Disposal
System at:
................./42...�4..ham =-sT-••••-•----../llo�isl0%.
ocation-Address V # o
............... ----•-------•------------------ Jv 4WAIiytii......... ;,Lseo.
..........................
. ..
O
. ner Address i
---•-••----------- . ......-
Installer Address
UType of Building Size Lot............................Sq. feet
Dwelling— No. of Bedrooms-------3--------------------------------Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No. 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................
x Disposal Trench—No. .................... Width.................... Total Length-------------------- Total leaching area....................sq. ft.
3 Seepage Pit No--------------------- Diameter------_-.---_-----. Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
0.4 Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water--.--...................
fXq Test Pit No. 2................minutes per inch Depth of Test Pit.....--.......--.... Depth to ground water.........--.............
P4 --------------------- - --- :-- - ----- •------ -----------------------------•--------------• --•--------------------------...--••-•----...----------'
0 Description of Soil-----------------------. �-!"-
---
W
---------------------------------- ---- ----
Nature of Re airs or Alterations—Answer when applicable h.S I�_-.Q v,✓- lo-.kY....
U P PP --------------------•-----
•-----------------•--•------•------------•------•••----------•••--•-...---•-------•--•...---•--•-•••---••-----••-----•-------•--------•----•-•-------••--•-----•-----•------------------••----......•---
Agreement: -
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliant s be issued by the board f health.
Signed ---------------- ---------- --- ................. �— 9 y
----------------- --- - ......... ----
Dare
Application Approved B57
'
PPPP Y -' ............. .... - ...----------. - --------------. ------------- ..- ... ..............--........
Dare
Application Disapproved for the following rearons:
'.. ........ --- ..................... _........... ..........._...................... .............................................
re
Permit No. ��f'.....:f� 1� Issued ..... �� .....................................
Date
_f
No.._/_. ..... Fis....��U ...........
THE COMMONWEALTH OF MASSACHUSETTS�
BOARD OF HEALTH 1419 - 00cj
OF BARNSTABLE
Aplil ratio t for Diiipotial Wor1w Cnonstrur#tun meat#
Application is hereby made for a Permit to Construct ( ) or Repair (L__�an Individual Sewage Disposal
System at:
3 /�,y
-• .....-.-•. l.,//....C! .4�h6/ T /.du
/[�/G/!s/p ri< i//c
ocation•Address or Lot No. .
,�/G�h �!- /.!2.gc!kt_..._----•-------••••........... .......................l v...lti y Sy �y s1 h s !..��s
.._..._.
O vner Address
a l,H tH�/�llt
d ess
Type of Building Installera ---------•-•-••----------•----•.'..-Size rLot...........................Sq. feet
V ._Dwelling—No. of Bedrooms------- _ _Expansion Attic ( ) Garbage Grinder ( )a Other—Type of Building ............................ No. of persons..._........................ Showers ( ) — Cafeteria ( )
a' Other fixtures ............................... . .
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.
3 Seepage Pit No.:.................... Diameter-------------------- Depth below plet___..__............. Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date.........................................
a Test Pit No. I________________minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
f14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
1:4 ---------------------
DDescription of Soil........................ ----------------------- - ----------------------•---....--•---------.........................................................
x .
W
Z. -••••-•--•--------------- ---------------------------------------------------------------------------------------------------------------------- ----------------
U Nature of Repairs or Alterations—Answer when aPPlicable.____ h Sr l 00
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliant s be n issued by the board f health.
Signed --------- �' �G/
2 9-
A lication Approved B -------------- �~ �r.
Date 1
Application Disapproved for the following reasons: ------------� ...................................................... .......................
......................................................................................... ... . ... . . ........ ........................................
re` —
Permit No. . -- �✓ -�----- Issued .......... --._...._..........._. - Date ...................................
---------------------------------------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
QPrtifirate of (fIImplittnrE _ -- - - -
THIS IS TO_.CERT FY, That I i e dual Sewage Disposal System constructed ( ) or Repaired ( �)
... / .... - - - ............ _......... ......... ..........
t net
at ..-------/ .......0451"'V.4 ----- --- '----4�----- '' 1�.'-- - '/---------. -- ----------------------------------------------
has been installed in accordance with the provisions of TITLF of The State Environmental Code as d scribed in
the application for Disposal Works Construction Permit No. �,tC->..._ ..' j .. dated ....6.._.._:. .:.._�..
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. !!54
DATE-----------17 / ...... . - __-------------------- ---- Inspector --
,ram
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE �_�
No..... .................. FEs._._........._.. `
Permission is hereby granted V-_U ....................................
v 1
to Construe or Repair an Individual Sew Disposal System E
at No........ .l l�r��2 � U -•�;-�------
Street
as shown on the application for Disposal Works Construction Permit o��._���Dated__..4-.."
Board of Health
DATE........... 1�........................
FORM 36508 HOBBS R WARREN,INC..PUBLISHERS
- °� TOWN OF BARNSTABLE
LOCATION 1.5-/ ZJ.4G11U7- Si SEWAGE #l-' �,-j 5-l
VILLAGE_ A94,egnA4s /"91LLS ASSESSOR'S JAAP & LOTJ 49- o69
INSTALLER'S NAME & PHONE NO. Jef/,✓
SEPTIC TANK CAPACITY_ /dD l� C�i9I-L d i✓S
LEACHING FACILITY:(type) GIs (size) '6
NO. OF BEDROOMS PRIVATE WELL. OR PUBLIC WATER
BUILDER OR OWNER F/,f1AJ,5- �a�Sii✓EAL/
DATE PERMIT ISSUED: -� -
DATE COMPLIANCE •ISSUED:_
VARIANCE GRANTED: Yes. —No /°
�- Al.
is`� WA4 AIvr �7 ��
spy r� lo�pj o,f 6���►s t4Gf� 7
8UBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM '
Address of property 1 S1 Wi In v 7`
Owner' s name E/4,h e Cates 'n e�✓
Date of Inspection
9 S-i)= ys-
/91 PART A
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 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.
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 site was inspected for signs of breakout.
All system components, excluding the SAS, have been located on the
C site.
✓ 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.
✓ The size and location of the SAS on the site has,been determined based
on existing information or approximated by non-intrusive methods.
The facility owner (and occupants, if different from owner) were
provided with information on the proper maintenance of SSDS.
� M
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION '
FLOW CONDITIONS
If residential
3 number of bedrooms
number of current residents
/VO garbage grinder, yes or no
Y&3 laundry connected to system, yes or no
Ai4 seasonal use, yes or no
If nonresidential, calculated flow: t'
Water meter readings, if available: 3 570 - cor-re•i�"
Pte.5 ^�� ,�D � O o � - L 4 fT ia? -3/
- qe z.,,iP'`a Last date of occupancy 7a y o 0'0
GENERAL INFORMATION
Pumping records and source of information:
10 System pumped as part of inspection, yes or no
if yes, volume pumped
Reason for pumping:
Type of system
✓ Septic tank/distribution box/soil absorption 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. Source of
information:
11o✓j e bv,'�f i.1 /-1/ 79 Over-C/o e-c A a t �n f 14
- in JVAP 0 I ? 9'-/ s� -r�e - Owe�r rd S�st.,//rr
NJ Sewage odors detected when arriving at the site, yes or no
J
s
9
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
/ .SYSTEM INFORMATION continued
SEPTIC TANK: j
(locate on site plan)
depth below grade _
material of construction: ✓ concrete metal FRP other(explain)
dimensions: 5tgl,c 71 /( V, 6 y k 'k Loamy
7 s
sludge depth
distance from top of sludge to bottom of outlet tee or baffle
scum thickness
k" distance from top of scum to top of outlet tee or baffle
j distance from bottom of scum to bottom of outlet tee or baffle
Comments:
(recommend#tion for pumping, condition of inlet and outlet tees or baffles,
depth of liquid level in relation to outlet invert, structural integrity,
evidence_of leakage, recommendations for repairs, etc. )
LeoiCS *o lit' 6,•of Co r� fi�7 Unc� y� n��.•��; nc /o%tr�c7
e�—
!7'-rt C-e4.1,Yr ✓: -�i'I, +h t- * Tl,- t Tiv✓lr .
C - ,
DISTRIBUTION BOX: 5 X �0 �L ,X do
(locate on site plan) ,),FTA Of Lover ;s le'" b�10,1 yr4>Ce
0 depth of liquid level above outlet invert
Comments:
(note if level and distribution is equal, evidence of solids carryover,
evidence of leakage into or out of box, recommendation for repairs, etc.)
I� '��f .�
%'�9 c-r �P c e •F r,�� c' n C S c�5 Cc'/!' y O!'P/`
PUMP CHAMBER: y�
(locate on site plan)
pumps i orking order, yes or no
Comments:
(note condition of pump c ez --condition of pumps and appurtenances,
recommendations for maintenance\or repairs,etc. )
10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
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 fir,s Ny off/ - X to
✓leaching pits and number v? - Od/O la k
leaching chambers and number -_y
leaching galleries and number
leaching trenches, number, length
leaching fields, number, dimensions
overflow cesspool, number
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding,
condition of vegetation, recommendations for maintenance or repairs,etc. )
�3ksea( o,� Fx,'sf '� 5 i.�-F'oI^✓r147�, a��
CESSPOOLS (locate on site plan)) 1
number and configuration
depth-top of liqui to inlet invert
depth of solids layer
depth of scum layer
dimensions of cesspool \ �,
materials of construction
indication of groundwa.tefr
inflow (cesspool st be pumped as
part of inspec 'on)
Comments: -
(note cond ion of soil, signs of hydraulic failure, level *of ponding,
condition of vegetation, recommendations for maintenance or repairs,etc. )
PRIVY: /yh
(locate on site plan
materials of construction
dimensions
depth of solids
Comments:
(note conditi of soil, signs of h drAulic failure
, - level level of ond 'in
condition � P g�
of vegetation, recommendation"or maintenance or repairs,etc. ) -J
E
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
- PART B
SYSTEM INFORMATION continued
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
ro
14
j /l3
a C)
125 3,7 l
L. i? � ,� �✓Pc�lot/
Lcuch t
DEPTH TO GROUNDWATER
depth to groundwater
method of determination or approximation:
7
F
12
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .
PART C
FAILURE CRITERIA
Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of
determination in all instances. If "not determined", explain why not)
NV Backup of sewage into facility?
N° Discharge or ponding of effluent to the surface of the ground or
surface waters?
,410 * Static liquid level in the distribution box above outlet invert?
/4//4 Liquid depth in cesspool <6" below invert or available volume< 1/2 day
flow?
A10 Required pumping 4 times or more in the last year?
number of times pumped ;
Septic tank is metal? cracked? structurally unsound? substantial
infiltration? substantial exfiltration? tank failure imminent? l
Is any portion of the SAS, cesspool or privy: 'J
//0 below the high groundwater elevation?
within 50 feet of a surface water?
/4/10 within . 100 feet of a surface water supply or tributary to a surface
water supply?
/V0 within a Zone I of a public well? .
/✓'✓ within 50 feet of a bordering vegetated wetland or salt marsh
(cesspools and privies only, not the SAS) ?
within 50 feet of a private water supply well?
NV 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.
13
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORK
PART D
CERTIFICATION
Name of Inspector
Company Name John A. A., /to 5erv,'cf .
Company Address /5_o pl/".;./ham f S f /tur S7`�� s ex-• It4 C)a 1/' elf
Certification Statement
I certify that I have personally inspected the sewage disposal system at
. this .address and that the information reported is true, accurate and
complete as of the time of inspection. The inspection was performed and
any recommendations regarding upgrade, maintenance and repair are
consistent with my training and experience in the proper function and
maiitenance of on-site sewage disposal systems.
Check one:
V' I have not found any information which indicates that the system fails
to adequately protect public health or the environment as defined in
310 CMR 15. 303 . Any failure criteria not evaluated are as stated in
the FAILURE CRITERIA section of this form.
I have determined that the system fails to protect public health and
the environment as defined in 310 CMR 15. 303 . The basis for this
determination is provided in the FAILURE CRITERIA section of this
form.
Inspector's Signature
Date
Original to system owner
Copies to:
Buyer (if applicable)
Approving authority
LOT 7 j
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SEPT/C 3Y3T�M COu�/,STQG/CT/ON � $E..D'�OOMS'
_ SNAL4 .COA/FO.eM 70 MASS. 0e-5/G/V FLOW
ENV/QONAf&"rAL CQDI. Tiltd Y -/GW Y -----
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MANHOLE CO✓Ej, 7b.&X r& /Z> TO /MPEQ✓/Oc/S COVEa¢
- AV TN/N /'OF F/I�//SNEO G,e p DE TO PRE VEiNT.F/NE5
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AND ZEAC/I/NG .o/T
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A C0.VC,e67-6 1�7--EN67;V 30
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BY C 20%t,'ELL f• 7;AYLOZC2DZV,`" �_- H-/O LOAD/N6
Sy l"//L.L 0W S T.2&ET l�E'�, ,as �.
., - r �DVE° •� WA NOT TO BE I-OG��M0J7�/ 27-, AJA SS. 7O � 3YST6 /n/LE5 N-Zop
r NEFE&Y E.EKTIFI THhT TPL Er. lP1J De=S/G/V LOAD U
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TY
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OF 'TE T:JWt) OF t?AkrJ� ,/;,^-,Lp
r nE¢ty1jLE?;>Ai2f11. 2D 2 2obOC° �O�/sTEQ y j DATE N4Az_7;•/ A4Se_V7-
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KEY NUMBER <5685 >
NAME <COUSINEAU, ELAINE > B—C 1 B—C 2
B—C 3 B—C 4
STREET 151 WALNUT STREET
CITY MARSTONS MILLS ST MA ZIP 02648-2102 REF 1 REF 2
PHONE ( ) — REF 3 REF 4
METER NO.< 5338> DATE READING CONS
STREET <WALNUT ST NO. 151> 12/31/94 805 66 """
CITY MM D L9 ST LOC 06/30/94 739 35
PHONE ( ) — 12/31/93 704 55
06/30/93 649 28
ROUTE NUMBER 04 12/31/92 621 40
SERVICE DATE 11/28/77 06/30/92 581 19
METER DATE 01/0_/84 12/31/91 562 43
CAPACITY 7 06/30/91 519 26
STYLE T10
SIZE 1 RATE SCHEDULE
KEY PIT , PLASTIC
NOTE RR RIGHT BY ELEC ADDITIONAL CONS 0
ALTERNATE MIN 0
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
(fPr#ifirtt#P of CLomplianrE
THIS IS TO ERT�� That� al Sewage Disposal System constructed p )
J �h g p y ( ) or Repaired
by...................................... /1 �/1'
at .....-../r /..... -4� - ...�/Y'T ivy-..-.- .�..1..-- .4_.s................................................
has been installed in accordance with the provisions of TITIE,.�of The State Environmental Code as d scribed in
the application for Disposal Works Construction Permit No. ....�...�r....��:`�.:..--.. dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUEA AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
--✓ 9�
DATE........... ........1.:................ ...j .....__....._......._.__..-: Inspector ........._1.-�.. _,...6/........_._............-... -
t�Ef�
%
A
FROiV� pP /7�ovs'� 9S/ yYAl�v/
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Mood Stem Cong;truc t n 30ermit
1
` Permission is hereby granted to Construct( Repair( )Upgrade( Abandon( )
System located at 15S/ Gl/a A k t
ire 1✓/a e P- /S"x
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:Construc ion ust be completed within three years of the date of this ermit. r
Date: -SM G Approved by
,THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of (Compliance
THIS IS TO CERTIFY,thatt}he�,On-site Sewage Disposal System Constructed( )Repaired( Upgraded( )
Abandoned( )by _ �(f 1
�d at ZS Z 11,14 6 'd'- SA-� Al 44 has b n constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. / `/ dated 3-X
Installer Designer
The issuance of this pe it shall not be construed as a guarantee that the s will s des' ed.
Date 3 o Inspector
f
COMMONWEALTH OF 1VIASSACHUSETTS
�. EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL'PR ECTIO
RECEIVED
APR 1 0 2001
2
oW
TOWN ur oAruvSTABLE TITLE 5 f N LT' RN
P A
OFFICIAL P -.NOT FOR VOLUNTARY A E
SUBSURFACE SEWAGE DISPOSAL SYSTR1 FORM
PART A
CERTIFICATION
Property Address: /$/ we /i,
Owner's Name: P_ *Ielr/t�(Lt/�G2�A'''" R-
Owner's Address: >S/ Ui,; bi -t-
44,74, Ma, o2d12r
Date of Inspection: 3- /5-- O/
Name of Inspector:(please print) TO
Company Name: Aoi It, /SacAoe SPrt,,�a_
MailingAddress: j2 Li(- t S
*14 je I o 4 s All,1J, 411k PI"f
Telephone Number:S"o g- ya - 777!j
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.the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of-on site sewage disposal systems.I am a DEP
approved system inspector pursuant to Section 15.340 of.Title,5_(310 CMR 15.000). The system:
j,
Passes -►}r
✓Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date:
The system inspector shall s mit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 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
DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving .
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future'under the same or different
conditions of use.
'v
Title 5 Inspection Form 6/15/2000 page I
Page 2 of 11
r.
OFFICIAL INSPECTION FORM—l�C)'T' 'OR VOIlUNTARY;ASSESSM .N FS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM k;
PART A '
CERTIFICATION(continued]
Property Address: /5) Wu/n u f is ' i
Owner:'i i7hN e IlaJ&
Date of Inspection: 3/S-Q/.
Inspection Summary: Check A,B,C,D or E/ALWAYS complete"alI otSaltb�:D
c . .
A. System Passes:
I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
I/ One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. .
- 1
Answer yes,no or not determined(Y,N,ND)in the for the following statemenf If"not determined"please
explain.
A/ The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally
li unsound,exhibits substantial infiltration or exfiltration or tank faihae Is imminent System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or breakout or high static water level in the distribution box due to broken or
n settled or uneven distribution box.System will s inspection if with
obswctedpipe(s)or due to a broke s
Y P� (
approval of Board of Health): +
broken pipes)are rrplaced
obstruction is removed
V distribution box is leveled or replaced
ND explain:
The system required pumping more thad 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
' kM�
2
Page 3 of 11
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
J SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM
PART ., %;�►,;
CERTIFICATION;(continued)
Property Address: 5 l iZ/a A Sf
Owner: /ghnt /�a ffo
Date of Inspection:
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health,safety or the environment.
1. System will pass.unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,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 Supplierf f.jny)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
_ The system has a septic tank and SAS and the SAS is,within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more froN a
private water.supply well".Method-used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered.A copy of the analysis must be attached to this form.,
3. Other:
3
Page 4 of 11
OFFICIAL INSPECTION FORM—NOTE k'OR VOLUNTARY ASSESSMENTS
I Ai:°SYS"TEM:INSPECTIONYO
SUBSURFACE SEWAGE D SPO$ R1l�,,�1:•:
PART.A y
CERTIFICATION.^(mitmued)
Property Address:
Owner: /7"He
Date of Inspection: '3 /S"- O/
D. System Failure Criteria applicable to all systems:. .;.�_,,
You must indicate"yes"or"no"to each of the following for aft inspections
Yes No
Backup of sewage intd facility or system component due to 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 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''/2 day flow
_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
_ Any portion of the SAS,cesspool or privy is below high ground water elevation.
Any portion of 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'301eet'fromzprivate water
supply well with no acceptable water quality analysis. [This system passes if the weRmater analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this forma
(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of.10,000 gpd to 15,000
gpd•
You must indicate either"yes"or"no"to each of ibefollowing:
(The following criteria apply to large systems in addition to the criteria above)
yes no
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 suppts.Arr
the system is located in a nitrogen sensitive area(Interns Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large.system has failed.The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The system owner should contact the appropriate regional office of the Department.
4
44-%,
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: /�� G/✓u/.,yf5t
/1�/ M,/h A4.
Owner: AHAle tea!t
Date of Inspection:
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
_ Pumping information was provided by the owner,occupant,or Board oPH9alth
Were any of the system components pumped out in the previous two weeks?
_ Has the system received normal flows in the previous two week period?
✓ Have large volumes of water been introduced to the system recently or as part of this inspection?
V_ Were as built plans of the system obtained and examined?(If they were.not available note as N/A)
_ Was the facility or dwelling inspected for signs of sewage back up?
_ Was the site inspected for signs of break out?
/hL/N���•►ir
✓_ Were all system components,@xelamfing the SAS,located on site?
(/_ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site hg teen determined based on:
Yes no
✓ '— Existing information.For example,a plan at the Board of Health.
_✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)[310 CMR 15.302(3)(b)j
5
Page 6 of 1 l
OFFICIAL INSPECTION FORM—NOT FOR.YOI UNTAkY ASSESSMENTS'.
SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM
PART C '
SYSTEM.INFORMATION
Property Address: /5-1 Wahl- t St
Arj vn s i S, Ci,_
Owner•
Date of Inspection: 3—/S'd/
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 33y�P
Number of current residents: ;3
Does residence have a garbage grinder(yes or no): Alo
Is laundry on a separate sewage system(yes or no):No [if yes separate inspection required]
Laundry system inspected(yes or no):
Seasonal use:(yes or no): No
Water meter readings,if available(last 2 years usage(gpd)):
Sump pump(yes or no): /110
Last date of occupancy: or-c 6 , )e�/
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgR,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no):_
Non-sanitary waste discharged to the Title 5 system(yes or no):_
Water meter readings,if available:
Last date of occupancy/use: < ,
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the inspection(yes or no): Ves
If yes,volume pumped:/090 gallons--How was quantity pumped determined?
Reason for pumping: hlo'i'/¢r,anc-o
TYPE OF SYSTEM
Septic tank,distribution box,soil absorption system
_Single cesspool
_Overflow cesspool ,
_Privy
_Shared system(yes or no)(if yes,attach previous inspection records,if any)
_Innovative/Alternative technology.Attach'a copy of the current operation and maintenance contract(to be
obtained from system owner)
_Tight tank _Attach a copy of the DEP approval
Other(describe):
Approximate age of all compoNpts,date installed(if known)and source of information:
A,4, D� * LP J�s/�llt��� /97 2ft k4c4,D"t 1hf�af�o� �une /94N
Were sewage odors detected when arriving at the site(yes or no):
6
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C ;
SYSTEM INFORMATION continued"
Property Address: /S/ f.G'�1,,,41 57,
Owner: �Vhh.e /��
Date of Inspection:
BUILDING SEWER(locate on site plan)
Depth below grade: IS**'
Materials of construction:_cast iron 40 PVC other(explain):
Distance from private water supply well or su ion line:
Comments(on condition of joints,venting,evidence of leakage,etc.): '
SEPTIC TANK:_(locate on site plan)
Depth below grade: 9
.Material of construction: concrete_metal_fiberglass_polyethylene
_other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(ye4 or'no):_(attach a copy of
certificate) ^'►
Dimensions: S x 41 s X y '
Sludge depth: 6"
Distance from top of sludge to bottom of outlet tee or baffle: /8"
Scum thickness: IV
Distance from top of scum to top of outlet tee or baffle: 3��
Distance from bottom of scum to bottom of outlet tee or baffle: /8
How were dimensions determined: nc•(
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
�n�c GG�ts�i ivh �v in lcf je eVC, ok fllf T e f-Pfyi�
C i
GREASE TRAP:_(locate on site plan)
Depth below grade:_
Material of construction:_concrete metal_fiberglass_polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
Page 8 of l l
OFFICIAL INSPECTION FORM NOT-F:OR VOLUNTARY.ASSESSMENT_S
SUBSURFACE SEWAGE DISPOSAL.SYSTEM.INSPECTION FORM:
PAR' C Y
SYSTEM INFORMATION(continued)
Property Address:/ {1/ ti N
Owner: 19n
Date of Inspection: 3-/
TIGHT or HOLDING TANK: (tank must be pumped at time of i0)(4tate an site plan)
Depth below grade:
Material of construction: concrete metal fiberglass Polyethylene other(explain):;,., 1,
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: ' Alarm,in working order(yes or no):•
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: (if present must be opened)(locate on site plan)
Depth of liquid level above optlet invert: O
Comments(note if box is level2md distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
Ar,
PUMP CHAMBER: (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,conditio ofpumps and appurtenances,etc.x
,A
8
Page 9ofII
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: /3"�I iG I4. t 5t
Hvs
Owner: "Vhn e !1a
Date of Inspection:
► . SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number: '2,
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.):
,'f ti4 ',(�' N,� ���1 l �h� ,C���• t NHS ,�,s'L. 1.,��'1p��1
CESSPOOLS: (cesspool must be pumped as part of inspection)(Iocate on site plan)
Number and configuration:.,
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(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
4 `
Page 10 of I I
OFFICIAL INSPECTION FORM—NOT,'FOR.VOEUNTAIZY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART:C' .
SYSTEM INFORMATION(continued)
Property Address: /S/ axalsi f.Sl
Owner: ,Vyme !fa/t
Date of Inspection: i
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or,
benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.
27.
Yo covlrj
p z 2 s 32'
y9
r�i�.P 3 �hs11�0 3 . .. .
LI N C
h 7
r
10
Page 11 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBS,URFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM
.;. PART C
SYSTEM INFORMATION(continued)
Property Address: /r/ W/aw f Sf
Owner: `itie /7v fv
Date of Inspection:- 3—/3'-O/
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 16 feet
Please indicate(check)all methods used to determine the high ground water elevation:,
Obtained from system design plans on record-If checked,date of design plan reviewed: 7—s'
✓Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
✓ Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
f64,..r&-J well accrvss steel* was 2 6' 7P tv�f�r
fatid iy A, G.rtk is /,n,e/
oK• o �i f .s cf�Busf /N' ahr;v{ w� 1r �
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4D , P.eoPoSE.a
SEAT/C SYSTEM/ Cps/3TQUCT/ON � SE�'�OOMS
_ -- SHALL CONF02M 70 MASS. OES/GN FLOW
1 ,ENV/QO+vMENrAe- COOL TITLE Y `
..Or.�sro..-•9' .,. -TT f r,ry I., .__.. ..--........is.w er.+ ,�es.A P—
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MAN//OLE{CO✓EM 7 EXTEND TO 1MPE2✓/OC/S DOVE¢
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a 5 I O /A/F/L7;eA7/N6
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'Y- /000 New /�-/cbor " 200
_ 'VAS HEO
GALLON. _L jAlmeT d V i STONE
/NVEQT CAf AC/TY /A/✓EQT (}. $SILL
SE oT/G TAN.0 Ed EV' :4.20UN0
�WATE2T/6NT� /NVEQT �' 60�� OF
/NVEBT �:c•' P/T'�/
N ;AZ8AGE G2/NOE Q 40-5 c�
S/TE PLAA1 PRI-I �SE� SEI�tiGE
L OCA-rlo" 1./.r �I•-. ,
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.`
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' y wq.o 'iTO.45G OF, 12E✓NFO,eCEO GOA/C.¢6T6
I r)r!n+ �T F.�•�+e y razE.V6T 7/ 3Q .y/N.
�' ` � �. ;♦STEEL 20000 ••
BY C2p%�'ELL f 7-,A}/LO.r?G27PP'' H-/O LOAD/NLS
�., ,. :� /VEW.dV .NOT TO BE LOc=tTED
Y.4.eM01�77/�2T, NJASS, DTI-rI r ? OVee 3s!�5► BM C/^/LEsS H-20 S HEF.Eav CCFJIFI TNfiT T P- E Y •TINs DES/GA/ LOAaiNG /S LSeD.
Fo',tlDr71-)IJ LL:.r:'rarr, T � L•;t:
I.rl;T1r :COY `y� �/
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F °� cIsTEP y0Q� OATS NEQLT7� st6F�/T
\SUS/ 4 nPBOV.4L
No.
Fee S-0,
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: _,_Z1
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
01ppYicatton for jDigpo Y *ps�tem Construction Vermtt
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) El Complete System El Individual Components
Location Address or Lot No. �S� �/��`�,.? sf Owner's Name,Address and Tel.No. 5
Assessor's Map/Parcel +O� g T
,// Al
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
j G: /IQ /fo
Type of Building:
Dwelling No.of Bedrooms 3 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) �Opeh 144-C' X
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 t 's Board of Health.
Signed Date
Application Approved by Date —1b —O
11
Application Disapproved for the following reasons
Permit No. Date Issued
i
No. _ / Fee J _ /-
' THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
' r Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS
0(pprication for Mig o r *pgtem Congtruction Permit
Application for a Permit to Construct( )Repair( Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 15'/ v1/� {�d7 st Owner's Name,Address and Tel.No. �.D ��y c/
,14,f77h j �,i/s A9vasyf f1,��; A4,/f�
Assessor's Map/Parcel u9-00 j% .4v. 4 .-l '.5
T
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
�G. AR /tv y�lc-yss
/;1
Ait GV 1/,-S 0,//s xq
Type of Building:
Dwelling No.of Bedrooms 3 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) ken 4'e,P ,�P_dn X
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 bX this Board of Health.
Signed �m Date 3
Application Approved by Date /6 —U/
Application Disapproved for the following reasons
Permit No. Date Issued
----------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
(Certificate of (Compliance
THIS IS TO CERTIFY,t a On ite Sewage Disposal System Constructed( )Repaired( Upgraded( )
Abandoned( )by "J—C that
at _ ��/ C✓� _F; .�e.e.�j A 144 has b en constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No.—?," /`/ dated 3 ld Cl
Installer Designer
The issuance of this pe it\shall not be construed as a guarantee that the s s , will ctioa s des'g�d.
Date 3 ��— Inspector _
No. � � � �'� --------------------------Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
x1h5pogar *pgtem Congtruc n Permit
Permission is hereby granted to Construct( )Repair(A)Upgrade'( Abandon( )
System located at
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 rrwst be completed within three years of the date of this ermit. r
Date: �� Ol Approved by
7� soy
LO-CATIO
N' I�° '�-3CT SEWAGE PERMIT NO.
S�J / L'�'c9�N u� ✓
VILLAGE
I N S T A LLER'S NAME & ADDRESS
BUILDER OR OWNER
�
r , �0r�h (�/reo riah
Zyah1"1 s 4451
DATE PERMIT ISSUED _�� - 77
DATE COMPLIANCE ISSUED
a
� �
�� �
� r1 �'
i
� ,� " � '�'
� ,��'
�i �
'� �� '
if �`4�
72
07�,�
No................-.....-- Fps...fE'....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD Of HE LTH
.--------.OF......... ... ... . �!
Applir�ation for Disposal Works Toustrurtiun rrnfit
Application is hereby made for a Permit to Construct (<or Repair ( ) an Individual Sewage Disposal
System at
......, ............... .......5------------------------- .. - .....................
ocati /Address, or Lot�J //
L�r1%c.•-----------------•------- ......... /'$...Gf'L -------1=• .--5--------................-----
TL er Address
+�••�L1 ..........�b/ �-.......................................... ..................................................................................................
Installer Address
d Type of Building Size Lot.. r Qf._G._......--.Sq. feet
Dwelling 5L No. of Bedrooms_._..._..• -------_----:-.._-_-----Expansion Attic ( ) Garbage Grinder (�1-df'
p, Other—Type of Building ............................ No. of persons............................ Showers (I ) — Cafeteria ( )
a Other fixtes
d --------•----•-----------------------------------------------
W Design Flow.... ...........................•._gallons per person per day. Total daily flow.._ d... _.........__ Ions.
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? _ ] epth below 'Inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box (Y-4S Dosing tank ( ',Q � s - -7 7
~' Percolation Test Results Performed by....... c !i�__ _ ._ K.. �1:._...� :..__. Date.... `.'. . ............
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.........3.!�!....___.
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
GG x ........... ............¢...••---- -- - -...WDescription of Soil --""--------- .. •- -----.. ..................••-•--•-----
UW ...----
--•--•---------------•-•....---••---•--•--•--•---•-••-•••-•--•--•---•---•----•-••-••-----------••-•---•---------•---------••---•------•-----•--•---•-•--•-••••-----•---•--...-•-•--•--•-•---------_.....
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 iITIE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee issued by e boar of health.
S' ne-'. ... � �.... -- --- ................... �.�-�(/.. .7.
Date
Application Approved BY Lam.. 7•7-----------
Date
Application Disapproved for the following reasons-.......................................... ---------------•------•------------- ..............•........
._._
----------------------•---•-----------•--•--•-----•---.......-•--------...---------•-----------•-----••----•--.......---------•••----•---•--------•---••-----------••......----•-......----------
Permit No........ .............. ---• Issued e�../......��.�-�•-----•----a�--•---
Date
0;773-a
G
No................_....... Fim.....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O I-1E LTH
. i'rt/y?..........oF......... . ....ram-f .
-. -.. ...
ApplirFa#ion for Disposal Works Tonstrurtinn ramit
Application is hereby made for a Permit to Construct (-- or Repair ( ) an Individual Sewage Disposal
System at:
...... .....�.�. ............. ....ff..... ------•...------•---------------------- ---•------•---- ........ ..........................................................
�Locat -Address, /h 1 or Lot�T /
...................... .. .!../S l_�i...., . ----- C'--.--._.....................
__-
Owner Address
a 701, r lid
Installer Address
d Type of Building Size Lot_..�.-._G---'_.-_-.Sq. feet
Dwelling v No. of Bedrooms---------�...........................Expansion Attic ( ) Garbage Grinder (i1<lp'
Other—Type of Building No. 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.. ........
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No---------- Diameter...�.` depth below jnlet_��.s..._. Total leaching area..................sq. ft.
Z Other Distribution box (Y)'. Dosing tank ( )/ I /
`" Percolation Test Results Performed by......E '�. f .....-.!��v- r.................6...... Date.... ............
aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.........:e)........
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
� ..---..---•-�-• • . t
Description of Soi��_.: y sr'"'�........ �' ---------��." ! .. =� rr Gt�l lcw
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 T I T 11Zj 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has belen issued by the board of health.
,t ....................
7
✓J'// ' ✓ Date
Application Approved By..... / = ! 'YI `.. ..-��/_�
-. ------_---
Date
-------------•--
Applieation Disapproved for the following reasons:......................................................
.....................•-------•-----•-----.....-----•-----.....---------•--...----•----------------.....-------------•---••-•----•••---•-••.............................................................
Date
PermitNo......................................................... Issued-......
ate
THE COMMONWEALTH OF MASSACHUSETTS
BOARD Qu HEALTH
................ lf' ....OF......... .. ....GrY?''i .................................._.........-----
(In#ifirtttr of Toutpliatur
THIS IS TO C TI That the Individual Sewage Disposal System constructed (�or Repaired ( )
Installer
Artat.'. �- ••�/• "F` T/I ----------- '��'+l- `',' .O�YE.0 ,C ..1�`I .. �. ICi ------------
has been installed in accordance with the provisions of r 5 of The State Sanitary Code as describ El in the
application for Disposal Works Construction Permit N _____ __________.. . ........ dated__-.- ................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WI . .FUNCT ON SATISFACTORY.
DATE............ .nt..--- ..I... .............................. Inspector..........P...t s---on- ..........................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�7 . --
No......................... FEE-4 ...............
Disposal park -C�na nr#ilan [rrnti
�/ ��
Permissio i hereby granted.....V.I'--��/Iit . ."'�'
to Con rug" ( or Re�air ( �a Indru•dual wage Dis osalystem �J ` a
---------------- ...........
��
----------------
Street
as shown on the application for Disposal Works Construction Perm t No.. ................ Datedl.-.l_`J'__.-:-7
. . ............
-------•---- .....
Board of Health
DATE `���--7 7
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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S HERE13Y CGRrIFY THHT THE EXfs"rlfvGV OF
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FOUNDAT1otJ LOChTlow 15 CORRECT /95 `
SHOWN RIN)U Dow5 COt4FoRM UJIT41 ;
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