Loading...
HomeMy WebLinkAbout0163 WALNUT STREET (M.MILLS) - Health 163 E NUT ST.CRr 5 n5 �'74 LDS _ i r I �7 ® - o / No. 9� -3� ;� �j° Fee S 5 0 .0 0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Zipprication for Di5poga1 *pgtem Construction Vermit Application for a Permit to Construct( )Repair( x)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 16 3 W a l n u t S t Owner's Name,Address and Tel.No. Assessor's Map/ParcelMarstons Mills, MA Larry Mahan 163 Walnut St, Marstons Mills MA Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No. Wm E Robinson Sr, Septic Sry PO Box 1089 , Centerville, MA 02632 Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder( np 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 sand Nature of Repairs or Alterations(Answer when applicable) Title 5 Leach trench repair consisting of a 60 ' leach trench and D-box connected to existing tank. Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this B Health. Signed ` Date Application Approved by Date Application Disapproved for the following reasons Permit No. �7— j- Date Issued ,9 ' t l 5*0 - Q 7� No. 97 3e ., ,.. Fee $50 00 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: i Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 0(pprication for -Migaaf *pztem Con!gtruction Vertnit Application for a Permit to Construct( )Repair( X)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 163 Walnut rut Owner's Name,Address and Tel.No. r Marstons Mills, MA Larry Mahan Assessor's Map/Parcel y 163 Walnut St Marstons Mills MA Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No. Wm E Robinson Sr, Septic Sry PO BOX 1089 , Centerville, MA 02632 Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( np 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 sand Nature of Repairs or Alterations(Answer when`applicable) Title 5 Leach trench repair consisting of a 60 ' leach trench and D-box connected to existing tank. Date last inspected: ' Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this f Bo h��Signed n Date/ -7 i Application Approved by Date 1=,2,9 � Application Disapproved for the following reasons Permit No. Date Issued Z THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Mahan (Certificate of (Compliance �. THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed ( )Repaired ( X)Upgraded( ) Abandoned( )by Wm E Robisnosn Sr Septic Sry at 163 Walnut St, Marstons Mills, MA has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 9 Z C dated / -2 P -f 7 Installer Wm F. Robinson Sr SetUtic Srv. Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date. -^ --.Z, 0 ` Inspector vim.... 'r No. 7 7" 3 e j Fee $5 0.00 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE,. MASSACHUSETTS k. Mahan wigpogar *pgtem (Construction permit Permission is hereby granted to Construct( )Repair( X)Upgrade( )Abandon( ) Systemlocatedat 163 Walnut St, Marstons Mills, MA by WM E Robinson Sr, Sept c Srv. and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. IZ .Z�� E Date: � �� - } 7 Approved by ,�.a /* li l NOTICE: This form is to be used for the.repair of failed septic systems only CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) I,William E. Robinson, Sr.-.,hereby certify that the application for disposal works construction permit signed by me dated/—r2-9- S 7 . concerning the property located at 163 Walnut St, Marstons Mills ,MA meets all of the following criteria: * There are no wetlands within 300 feet of the proposed septic system. * There are no private wells within 150 feet of the proposed septic system. * The obseved 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: L. DATE U' LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER 60 (Attach a sketch plan of the proposed system. Also if the licensed installer proposes a certification plot plan,this plan should be submitted). �`� � �, �' , � g l r � ��`-- � � TOWN OF BAKNSIA-BLL LOCATION �� 6 J CC�.c' f'� v l S-r- SEWAGE # ] 7 -,3 VILLAGE ��� /y�l 116 ASSESSOR'S MAP & LOT-- INSTALLER'S NAME&PHONE NO. ll 6 b /�- 4 a 1•- '7 5-- -7 SEPTIC TANK CAPACITY 16 G LEACHING FACILITY: (type) �, ` �� G 6 (size) L- ' NO.OF BEDROOMS BUILDER OR OWNER-29Z-4 N� A--- PERMTTDATE: -;�,F-9 COMPLIANCE DATE: —3 r Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom off'Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet • `rE ge of Wetland and Leaching Facility JIf any wetlands exist within 300 feet of leaching facility) Feet Furnished by C. i J IJ ' t i TOWN OF BARNSTABLE i ^o_ 67 6' LOCH 1 ION 104 l ,Sr SEWAGE # "3 VM7s;AGE �i l g // ASSESSOR'S MAP& 1,0456, INSTALLER'S NAME&PHONE NO. b Jl 6 2 S-7-7- SEPTIC TANK CAPACITY /6 6 LEACHING FACILITY: (type) �'.;-'1` �! — G 6 (size) �• / ' NO.OF BEDROOMS 3'°w BUILDER OR OWNER -W- ,, N AJ PERMIT DATE: COMPLIANCE DATE: I`'"•�r'e1 Separition`Distan5e Between the: `MaximumrAdjusted 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"faciLty) Feet �Edge_of Wetland and Leaching Facil#y-(If any wetlands exist within 300 feet of leaching'facility. )., Feet h Furnished by �} .� �\ 0 �� `� n i . x ��� __ -- ;� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Address of property WwP_51d1llS �1GCS /,�/w Owner's name S.sLu y ,�pp�ctf Date of Inspection �-o U 7< 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 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. 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION FLOW CONDITIONS If residential �3 number of bedrooms —L number of current residents 1/o garbage grinder, yes or i no laundry connected to Zos tem, yes or no 'A/0 seasonal use, yes or If nonresidential , calculated flow: Water meter readings, if available: Ca/L?�yTl V/ Last date of occupancy GENERAL INFORMATION _ Pumpin.g records and source of information: R- -gugO A�- eL,& ►ice .¢T tom. it ��3�c f�/.¢rr ��%!_�rtav Cd�r, � ixo 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: .S �o��x. � G�/� cS�sr�.�/ /.vsz.�u�-->> �%ov i7 i_976 ��7 ©.�/'Y�i�l'�'_ ('Di'✓ OP /,SPOS�t 1�7.�1T'L.5 ���ST.�C.��IG/T/ �-.tl/T i¢111� Sewage odors detected when arriving at the site, yes or no ..r:w..i..i.Ciw.....c..aa....4...s.:....::. ...—..._:e�..b.,...i.:.+.1.�..w.......n.:.w...x....... . .�:..w .4....L:./,,. _....� r...'.L...ir..............s.w._...�...c,...._...... .._.,_�.i.+ alua.:....w.'......_..,...........................�a ..e. __Sn..�'.. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SEPTIC TA17K: (locate on site plan) depth below grade: —,� material of Construction: X concrete metal FRP other(explain' dimensions:_ ��� � X '20 sludge depth 7/ distance from top of sludge to bottom of outlet tee or baffle _ scum thickness I I , distance from top of scum to top of outlet tee or baffle - _(L' 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, recommendations for repairs, etc. ) � 3S � - T /3 �57T1LiG DISTRIBUTION B0X: (locate on site plan) 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. ) PUMP.-CHAMBER: lDv44_6 (locate on site plan) .A1/4 pumps in working order, yes or no Comments: (note condition of pump chamber, condition of pumps and appurtenances, recommendations for maintenance or repairs,etc. ) 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B . SYSTEM INFORMATION continued SOIL ABSORPTIO1: 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: T feaching pit�, e d number dnVE /Q�', �M �e ,,i �Tr�'T) leaching c as and number leaching galleries and number /k" ,� nrJ CFT�/f7?�. ,72".— 7z7— 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. ) S ze CESSPOOLS ( locate or, sate .plan) S, [� i�.brT,Gfi9yp- U/�v �f�/7 /n/ �UT,Ti�" �SU$ Td SAP-7U�ig-y7oi1/ number and configuration depth-top of liquid :o inlet invert A11,4 depth of solids lase_ depth of scu., laver dimensions of ce_ssmocl materials of construction indication of groundwater inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil , signs of hydraulic failure, level of ponding, condition of vegetation., recommendations for maintenance or repairs,etc. ) PRIVY: (locate on site plan) materials of construction dimensions depth of solids f Comments : (note condition of soil , signs of hydraulic failure, level of ponding, t condition of veceaticn, recommendations for maintenance or repairs,etc. ) ...n.. ..:.iL.2.;::..:y...new._.,......_...._.................<..w .a...-.W r2u._w ,.._..-a. �r.a...s.._......_...._f.. ...._...n...ri[`.:.se.......,......Y..✓ fa.._.e.«...a..:.. _.............v._..ta ...,......._....e.�.«.-u..__._........,.._._.e.,.0.,.._.," SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100 ' �5 Gl/9��vaT ST��T DEPTH-TO GROUNDWATER 83� depth to groundwater .method- of determination or approximation: 1A,1Laic/ 6li/T 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) Backup of sewage into facility? Discharge or ponding of .effluent to the surface of the ground or surface waters? N� Static liquid level in the distribution box above outlet invert? ,E 5771UG 5�,572Fz7 4)0e�5 1V&T Liquid depth in cesspool <6" below invert or available volume< 1/2 day flow? IV Required pumping 4 times -or more in the last year? number of times pumped D Septic tank , is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? Is any portion of the SAS , cesspool or privy: below the high groundwater elevation? iV within 50 feet. of a surface water? within 100 feet of a surface water supply or tributary to a surface water supply? A 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) ? 1V1\ within 50 feet of a private water supply well? A less than 100 feet but greater than 50 feet from a private water supply well. wit.h 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 .nit:rogen. t, . " 13 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D CERTIFICATION Name of Inspector fl�lj/ �, INN h�OiS�� lea Company Name Company Address 77 �i7�) S�sud Gf/lG�y �liJ.� c22 S6 ,5 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 manitenance .of on-site sewage disposal systems. Check one: 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. �lz A8�e�77o�/ 5jsr�/ I have determined that the system fails to protect public health and the environment as defined in 310 CMR 15.. 303 . The bas this determination is provided in the FAILURE CRITERIA se �Pg00 S'n is form. AMY �y -� Inspector' s Signature V#N068HONE Date /STEP�`� s'9N�rna�Pa . Original to system owner Copies to: Buyer (if applicable) L,4u/�E�GFti/,�/.¢rl• 7,37����"vr `�/S'�s�4Sj � Approving authority ,�3.�%ivsT LE ,S1 r,'l KEY NUMBER <5010 > NAME CEPPICH, ALLEN H M'. > B-C 1 B—C 2 B—C 3 B—C 4 STREET P 0 BOX 1303 CITY MARSTONS MILLS ST MA ZIP. 02648-0011 REF 1 REF 2 PHONE ( ) 428-29.30 REF 3 REF 4 •fA METER NO.< 4533> DATE READING CONS STREET <WALNUT ST NO. 163> 12/31/94- 108 n'=,28 CITY MM D L2 ST LOC 06/30/94 80 26 PHONE ( ) 12/31/93 54 36 06/30/93 18 33 ROUTE NUMBER 07 , / 0 SERVICE DATE METER DATE 02/12/93 - � \ 12/31/92 6182 42 CAPACITY 7 06/30/92 640 29 STYLE T10F SIZE 1 RATE SCHEDULE KEY PIT X PLASTIC NOTE FRONT LAWN NP! ! ! ! ! ! ! ! ! ADDITIONAL CONS 0 ALTERNATE MIN 0 D afl on s • No..'_ �f�_....... �Q.........._...... HE COMMONWEALTH OF MASSACHUSETTS BOARD F H ALT 1� Xppliration -for 14-liviaoal Works Toot itritrtijjtt Prrutit Application is hereby made for a Permit to Construct & or, Repair ( ) an Individual Sewage Disposal System at: r . - -$/._. fix.. ........................ ............................._.. v aE. x. ' jLo No. ........s.... _.t .1�t3-w•1-•�il'�".---.. ..P.....•.1../...�x 'Yit. t .._........`f.•�.•..�...... - t . ................................... ....... .........-- Address wl Installer W Size Lot............................Sq. feet Type of Building U Dwelling lL No. of Bedrooms............. -------------------------Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) 04 Other fixtures ..............................................................................................................�•---......----......................... Q W Design Flow........................�V•--••-•----gallons per person per day. Total daily flow............: ............r............gallons. W Septic 'r.mk-LLiquid capacity�•D.H.gallons Length................ Width................ Diameter................ Depth............. ft Disposal Trench—No. .................... Widtl �... ... Total Length.................... Total leaching area....................sq. ft. x Seepage Pit No.......1-_•-•....... Diameter.�-�............./�epth below inle ................... Total leaching area..................stl. ft. Dosing tank �' /I- //- 7 Y Nj Other Distribution box ( ) g ( ) F t Percolation Test Results Performed by..................................... ••-•----••--•-••--•••-•............. Date....................................... Test Pit No. i................minutes per inch Depth of 'Pest Pit.................... Depth to ground watf r........................ Test Pit No. 2................t»inutes per inch Depth,of Test Pit.................... Depth to ground water........................ a ..................... ..... •-•--•---.-•... .... -- .... Description of Soil....-.f�................iF./'�!�... �� rw- ice. ... ,1....�..,7.....� 7y ...............•--•--••--......................................................---- -•......•.............-•-........ x Nature of Repairs or Alterations—Answer when applicable...........................•_._...---.----•----••-•-•••---••-------- U ............................................................................ 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 been issued by tly board of }teal 1. Sign it.........: / .. ............Date.... ........ LL6. ..................... 1't' .,� -'....2..'y...... Application Approved 13 /--�. -•- -..... Date PP PP y. .............:...... ..............•---................................................................. Application Disapproved for the following reasons:..... ............................................................•--•---.............---................................ ................................................................. Issued.-P....../.7----............---•----........ PermitNo..---•--------------------------------------------------- Date 1 THE COMMONWEALTH OF MASSACHUSETTS / i. BOARD O HEALT 7 ,/7 Z.............OF.....i.... . ...L ICL.. .. .... • Tertifirrate of Tout phaurr TI 1 TO C� 2T.1I That the Individual Sewage Disposal System constructed ( or Repaired ( ) .. ....... .. .... by....... 1j�all .. ... .. . .. i ...... at. ... oR • t... has been installed in accordance with the provisions of Article X Of Pe State Sanitary Code as de ibed in tile applicatZtn fbr Disposal Works Construction Permit No------.. . !r.. -.-•----•-- dated-•-/ -"-•l..(..-....7.y............... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE,CONSTRUED AS A GUARANTEE THAT THE „a- SYSTEM WILL FUNCTION SATISFACTORY. r= UAT1r.. .................... . Inspector....................... .�..----• ............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD F HEALTH r .. f.........O F.... ..... ...........................""' '/"........................ FEE..d No. :J..' .�.:. I ................. ark a rurtion Vrrmit ......•..... ............. Permission reby gr ttedam.. .....to Const ct ) or R .pai ( ) d• ideal ewage.D spos ystem 2 ..•••-• /..... �`. .... ........... W at NO ... �� ��I . .�f street � as shown on the application for Disposal Works Construction P t N " . DateclA7.��-�.7J �^ Boar ea- d of IiU'fi�?� / l DATE............(.. .....:.................................. FORM 1255 HOBBS & WARREN. INC..-.PUBLISHERS , . ...-.-.� - '�' �', .� �� � 7 / 1 !�' � � � � i V �I ,� . � �� i . . � - - - T _ _ ,.. � � . �__ LOCATION SEWO,C�E PE MIT Mo. &e Xx L--t u l LL AGE i IN`S A LER�S E � ADDRESS �� BUILDERt�1 .AUA.E)DRF S — — — — I -0. �� � � DATE PERNAIT 155UED _7 _ • D ATE CONIPLI :7- 1?-7S` Gt/a/ti S7 wcro �f r a LOC&TION ' SE\NJ&C,E PERMIT MO. V I LL AGE �G•c.s� � Iro�� — Ibis A LERS E � .ADDRESS _BUILDER _ Q_&ME. ADDRF- - - .DATE PERKAVT DATE COMPLI WACE ISSUED : - i000 �f �C /aL,.h ®,o n` e THE COMMONWEALTH OF MASSACHUSETTS BOARD F F-9AL�T lJ'llGd ... OF...... :' = G�✓ :.. ----- ...... Appliration -fur IN-41imittl Work,6 Towitrurtion Vanift Application is hereby made for a Permit to Construct & or Repair ( ) an Individual Sewage Disposal System at: � . � l�- o - 7 _.. ---- ---- ---- ------------------------------------- L -ss ( v Lot No. r --- .......= ----. . `�.:... 4 7 :,A.....4:4 tfe.l�........... ��............................................ ...a.... dress \ Installer Address Type of Building Size Lot............................Sq. feet U Dwelling No. of Bedrooms_-------- _________________________Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ____________________________ No. of persons-.-------------------------- Showers ( ) — Cafeteria ( ) a' Other fixtures ------------------------------- - -- - ----- W Design Flow........................e 0._.......__gallons per person per day. Total daily flow___..____-.-_•� _:—_------------gallons. WSeptic Tank Liquid capacity/Dl'i_gallons Length................ Width------.......... Diameter---------------- Depth-------------- x Disposal Trench—No..................... Width._.._ _____T___ Total Length-------------------- Total leaching area-------------.------sq. ft. Seepage Pit No._.._..I...__..._.. Diameter -�� .� -pth below inlet____________________ Total leaching area----- ft. i------- Z Other Distribution box ( ) Dosing tank ( ) i 'Z aPercolation Test Results Performed bY.......................................................................... Date-------------------------------------- a Test Pit No. I................minutes per inch Depth of Test Pit_._________-.-______ Depth to ground water.._._______._____.__.... f� Test Pit No. 2________________minutes per inch Depth of Test Pit.................... Depth to ground water............___._--_---- - ---------- ----------- - 0 Description of Soil----- h _ - A^� = ` YL p r�. ��_. - �' 7 r Gse -- ------ x -/ --- Ua-- - , � �' - f ----------------------- 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 Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by th;board of heal . Sign ..........• ._... ..........::......•---•-•---..._ Date Application Approved B !- Date Application Disapproved for the following reasons___________________________ ---• ..................•--------••.......................... ------........ Date Permit No......................................................... Issued...1.............. ................................. ...- -- -- ------------------- Date F' !: No. Fus.: Q....+............._ - �Ya* THE COMMONWEALTH OF MASSACHUSETTS--­, BOARD F H ALT No s /.. .�.•Gt O F... Application'i'g Hereby mRde fors a Permit to Construct (,, j or'Repair (19 an Individual Sewage Disposal ri vSyStem at ra: 4`�,44 i .d ?h 7�- ....... r°.'riW`!'•�• .............. ....................... ._ .._..................................... e� e • e 'Lot y��7 © J /Qgwfirer41 --Yir!S ,c!-......4 l.. •-----------------------•a:: 4'wc1._' f-]i.lTrC. _.. cr-N'" �!iH�!►, �""-" Installer .. Address Type of Build* t Size Lot----------------------------Sq. feet �A 'Dwelling •No. oil °Bedrooms_.."•-___.- ..._.. __-_`_-___-Expansion-Attic ( ) Garbage Grinder Other-Type of Building _................... .... No. of persons----------------_........... Showers ( ) — Cafeteria dOther fixtures . ------------------------------------------------------- ------------------------------------ ----•--------•----•------ W Design Flow_.., .............. P...........gallons=per person per day. Total daily flow------------�0"a_:-............gallons. Liquid cap,16 yl�"gallons,' Length________________ Width.. Diameter_.... ._..._...Depth.. _.__--- , C4 Septic 'T tnk Disposal.Trench—No .......__ ...tWidth... ....pp.. Total.Length-------____________" Totalrl°eaching area.._.___"-___--.....sq. ft. 3 Seepage Pit No......./------------- D.iameterh��...K pth below inle .................. Total leaching area____"_.____---._-sq. ft. z Other Distribution boxN( ) Dosing tank 7 Y � /► ;3♦�M� .~" Percolation Test Results Performed by------------ ........................................................ Date---------------------------------- Test Pit-No.-1.....:.........minutes p.er inch Depth of Test Pit._..._.._..__....___ Depth to ground water-..____"-.__..:..'.____ t-, s fs, Test�Pit.No:-2------------------minutes per inch Depth of 'Test Pit....................;Depth to ground water........................ T -A----------- .x ....- `mot --- 0 . .0 i .escripion,/ Soil---- - ---- ---- --- -- --- ----- ---=- ------------------------------------- ------------ --- -- ------------- V ,,Natur f Repairs or Alterations—Answer when applicable _"----"-""-.--_.""__"_""-._._"-."_-"-"._-"- -_ ---- ---------------------- . Agreement The undersigned agrees to install the--aforedescribed'ohndividual Sewage Disposal System in accordance with .0, the provisions of Article XI of the State Sanitary Code—The undeisigned further agrees not to place the system in operation ur4il a Certificate of Compliance-has been issued by the board of heal' . Sign - $1v �t ."_..-""/---%-t--."------ ' , D t_APPlication Approved By:------ .................... r -- .. Date Application Disapproved for the following reasons: ..._. _.......: ._... .................•-..............---•"-•---------••-••-------•--•---••..... Date Permit No-- ----------- .................................... x � Issued a F Date' $ THE COMMONWEALTH OF MASSACHUSETTS IPM BOARD O HEALT /..�L/�'Z.r...........OF........... ... ... . ICt... ........ • Trdifiratr of TlImpliaurr N" TH I TO C TI N, That the Individual Sewage Disposal System constructed (�r Repaired -- -- - ..__...--•--•- ---•-----•-,n all•---------._�_.----•-•--•r• �- �•- ---•-- , •- r • ._�. (f _.. •_�y� _�' .I- - '•gill��"' Y""' ' 1rL�'/_.. ._ / ............ has been installed in accordance with the provisions of-Article X of he State Sanitary Code as de ibed in the '-applidat on for Disposal Works Construction Permit No'..`.................... .............. dated-_;//.'-__/.�."....7 X THE ISSUANCE OF THIS CERTIFICATE SHALL NOT`BE,C}O(ISTRUED AS A GUARANTEE THAT,THE SYSTEM WILL'FUNCTION SATISFACTORY. iy•tii' +, DATE........................... Inspector---••-•. . ....---------------------••-----------... THE COMMONWEALTH.OF MASSACHUSETTS BOARD F HEALTH OF...... _.. -~ .... ............. � No...... ... EE i� u irk Cnu rudion Prrmit ' Permission ' reby granted''= `' � � ..•..... to Const ct ) or R pat ( `) d idual ewage` D spos ystem 1 i �/ �.. " at No - t ---- ..r'_ . .� �";� _ - Street as shown on the application for Disposal:Works Construction P t N 11""- DatedJ47 � _ ti f� DATE--------�•"`-•••• _ •"_-•• - .. Board of Aeae 4 FORM 1255 *OBBS & WARREN. INC..�PUBL�ISHERS , #r, -• f�;,,,,,f�:_ - - r aJ �- ( V\ u V i