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HomeMy WebLinkAbout0587 WHISTLEBERRY DRIVE - Health 587 WHISTLEBERRY'�ev.2 Y- M�I� A= 061 049 I, i � a COMMONWEALTH OF MASSACkSETTS 'f Ep ECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PRO, C%TI'0!� "< ONE WINTER STREET. BOSTON. MA 02108 617-292-550� �1r WILLIAM F WELD JUL s 0 1998 TRUDY CORE % 1 Sccre Lx-' Governor :: y►y TOWN OFBARNSTABLE / ARGEO PAUL CEE;LUCC1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FO HEALTH DEPT DA" DB.STRUHS PART A j Q Commissioncr Lt.Govemor CERTIFICATIONS/ Property Address: :S87 WHISTLEBERRY DRIVE MARSTONS MILLS r� I` ; _ r Date of Inspection: `.1ULY 28.1998 Address of Owner. Name of Inspector:,-.DAMES A.ORPHANOS (if different) I am a DEP`approved inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: .;CERTIFIED INSPECTION ASSOCIATES Mailing Address:;47 CAMERON ROAD NORTH FALMOUTH MA 02556 Telephone Number: (508)564-5653 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. The system: X Passes Conditionally.Passes _ Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signa Date: JULY 28.1998 The system Inspe for shall su mit a copy of this inspectio eport to the Approving Authority within(30)days of completing this inspection. If the system is a shared system or as a desi n flow of 10,000 gpd or gre er,the inspector and the system owner shall submit the report to the appropriate regional office of the Departmen of Enviro ental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authori INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTEM PASSES: X I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B] SYSTEM CONDITIONALLY PASSES: One or more system components as described in the"Conditional Pass"section need to be repaired or replaced. The system,upon completion of the replacement or repair,as approved by the Board of Health will pass., Indicate yes,no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached)indicating that the tank was installed within twenty(20)years prior to the date of inspection;or the septic tank,whether or not metal,is cracked structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 4/25/97) Page 1 of 10 D.9. 1 of 10 (revised 04/25/97) DEP on the wond wWe wet): http:/twww.magneLstate.ma.ur./OeP Pnnted on Recyo d Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 587.WHISTLEBERRY DRIVE Owner: AMELIA E.BARNICLE Date of Inspection: JULY 28.1998 B]SYSTEM CONDITIONALLY kSSES(continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. The system will pass inspection(with approval of the Board of Health). Describe observations. broken pipes)are replaced _ obstruction is removed distribution.box is leveled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection(with the approval of the Board of Health): broken pipe(s)are replaced obstruction is removed c]FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by.the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM_WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply: _ The system has a septic tank and soil absorption system and the SAS is within a Zone 1 of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50'of a private water supply well. _ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the.well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 PPM. Method used to determine distance (approximation not valid) 3) OTHER . (revised 4125197) Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Prcperty Address: 687 WHISTLEBERRY DRIVE Owner: AMELIA E.BARNICLE Date of Inspection: JULY 28.1998 D]SYSTEM FAILS: You must indicate either yes"or"no"as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303.The basis for this determination is outlined below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into the facility or system component due to an overloaded or clogged SAS or cesspool. _ Discharge or ponding of effluent to the surface of the ground or the surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 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 Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E)LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: . The following criteria apply to large systems in addition to the criteria above: The system serves a fa: .vith a design flow of 10,000 gpd or greater(Large System)and the system is a.significant threat to public Yes No The system is within 400 feet of a surface drinking water supply. The system is wit!in 200 feet of a tributary to a surface drinking water supply. The system is t.,d in a nitrogen sensitive area [Interim Wellhead Protection Area-(IWPA)or a mapped Zone 11 of a public water supp�,well.] The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 AMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 4/25/97) Page 3 of 10 y L+. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 587 WHISTLEBERRY DRIVE Owner: AMELIA E.BARNICLE Date of Inspection: JULY 28.1998 Check if the following have been done: You must indicate either"Yes"or"No"as to each of the following: Yes No X _ Pumping information was requested of the owner,occupant,and Board of Health. X _ 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. X _ As built plans have been obtained and examined. Note if they are not available with N/A. w X _ The facility or dwelling was inspected for signs of sewage back-up. X _ The system does not receive non-sanitary or industrial waste flow. X _ The site was inspected for signs of breakout. X _ All system components,excluding the Soil Absorption System,have been located on the site. X _ 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. X _ The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal System. The size and location of the Soil Absorption System on the site has been determined based on: X _ Existing information. Ex.Plan at B.O.H. X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) [I 5.302(3)(b)J (revised 4125/97) Page 4 of 10 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 587 WHISTLEBERRY DRIVE Owner: AMELIA E.BARNICLE Date of Inspection: JULY 28.1998 FLOW CONDITIONS RESIDENTIAL: Design flow: 110 g.p.d./bedroom for S.A.S. Number of bedrooms: 3 Number of current residents: 2 Garoage grinder(yes or no): NO Laundry connected to system (yes or no): YES Seasonal use(yes or no): YES Water meter readings,if available(last(2)year usage(gpd): N/A Sump Pump(yes or no) NO Last date of occupancy: THE HOME IS CURRENTLY OCCUPIED. COMMERCIALIINDUSTRIAL: N/A Type of establishment: Design flow: allons/day 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 OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: THE SEPTIC TANK HAS NEVER BEEN PUMPED ACCORDING TO THE OWNER. I RECOMMEND THAT IT BE PUMPED EVERY TWO YEARS. System pumped as part of inspection: (yes or no) NO If yes,volume pumped: 9allons Reason for pumping: TYPE OF SYSTEM X 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)and source of information: THE SYSTEM WAS INSTALLED ON 8/27187 ACCORDING TO CERTIFICATE OF COMPLIANCE#87-97 ON FILE AT THE BOARD OF HEALTH. Sewage odors detected when arriving at the site: (yes or no) NO (revised 4/25/97) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 687 WHISTLEBERRY DRIVE Owner: AMELIA E.BARNICLE Date of Inspection: JULY 28.1998 BUILDING SEWER: N/A (Locate on site plan) Depth below grade: Material of construction: cast iron _ 40 PVC _ other (explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints,venting,evidence of leakage,etc.) SEPTIC TANK: X jlocate on site plan) Depth below grade: 14" Material of construction:X concrete metal Fiberglass Polyethylene other(explain) if tank is metal,list age confirmed by certificate of Compliance (Yes/No) Dimensions: 4'WIDE X 8'LONG X 4'DEEP Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 31" Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 14" How dimensions were determined: DIRECT MEASUREMENT. Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,etc.) THE LIQUID LEVEL IS 49"AND SANITARY TEES ARE PRESENT AND IN SATISFACTORY CONDITION THERE ARE NO ADVERSE INDICATORS AND NO RECOMMENADATIONS. GREASE TRAP: N/A (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: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,etc.) (revised 4/25/97 Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 587 WHISTLEBERRY DRIVE Owner: AMELIA E.BARNICLE Date of Inspection: JULY 28.1998 TIGHT OR HOLDING TANK: N/A (Tank must be pumped prior to,or at time,of inspection) (locate on site plan) Depth below grade: Material of construction: concrete metal Fiberglass Polyethylene other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Alarm in working order Yes: _NO Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: X (locate on site plan) Depth of liquid level above outlet invert: 0.0" (,STATIC) Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) THE D-BOX IS LEVEL AND THERE ARE NO ADVERSE INDICATORS OR RECOMMENDATIONS. PUMP CHAMBER: N/A (locate on site plan) Pumps in working order: (yes or no) Alarms in working order:(Yes or No) Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) (revised 4/25197) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 587 WHISTLEBERRY DRIVE Owner: AMELIA E.BARNICLE Date of Inspection: JULY 28.1998 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,but may be approximated by non—intrusive methods) If not determined to be present,explain: Type: leaching pits,number: X leaching chambers,number: AS-BUILT CARD AT BOARD OF HEALTH SHOWS(5)4'X 8' leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: Alternative system: Name of Technology: Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) FLOW DIFFUSERS WERE NOT INSPECTED AS ALLOWED BY THE REGULATIONS. THERE WERE NO ADVERSE SURFICIAL INDICATORS AND NO EVIDENCE OF CARRY-OVER OR BACKUP IN THE D-BOX. CESSPOOLS: N/A (locate 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(cesspool must be pumped as part of inspection) Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) PRIVY: N/A (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.) (revised 4/25/97) Page 8 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 587 WHISTLEBERRY DRIVE Owner: AMELIA E.BARNICLE Date of Inspection: JULY 28.1998 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (locate where public water supply comes into house) FRONT 21.9' 33. ' 41.0' 33.0 48.0' 52.0' NOT TO SCALE TIES FOR FLOW DIFFUSERS ARE FROM AS-BUILT ON FILE AT THE BOARD OF HEALTH TIES FOR SEPTIC TANK AND D-BOX ARE FROM THIS INSPECTION. (revised 4/25/97) Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 587 WHISTLEBERRY DRIVE Owner: AMELIA E.BARNICLE Date of Inspection: JULY 28.1998 Depth to Groundwater >9.0 feet Please indicate all methods used to determine High Groundwater Elevation: Obtained from Design plans on record Observation of Site (Abutting property,observation hole, basement sump etc. Determine it from local conditions. X Check with local Board of Health Check FEMA Maps Check pumping records Check local excavators,installers Use USGS Data Describe in your own words how you established the High Groundwater_levation. (Must be completed) I CHECKED WITH THE BOARD OF HEALTH AND USED THE MASS GIS MAPS TO DETERMINE THE DIFFERENCE IN ELEVATION BETWEEN THE SUBJECT PROPERTY AND NEARBY MYSTIC LAKE. (revised 4/25/97) Page 10 of 10 r Y TOWN OF BARNSTABLE JAN'nOINN SEWAGE # VILLAGE f A A-bTous rA% L-..S ASSESSOR'S MAP& LOT Ub t•oy4-eS 'S NAME&PHONE NO. J pv^es d R RAAw S S6fr-56y-S6S 3 SEPTIC TANK CAPACITY 79aTV 614tiCdl WS LEACHING FACILITY: (type) Rut. -0,F N%enS (size) (/1-k g � NO. OF BEDROOMS : B OWNER /)r,-u A YZ1 n a P-J t c-L.L PERMTTDATE: COMPLIANCE DATE: Z1 1 Separation Distance Between the: 7J,P Jr g 7 b /I w S PeC71 or Maximum Adjusted Groundwater Table to the 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 Lc A a yam , J TOWN OF BARNST%iHLE L--7CATION Lo+ 4PE Loti,�S+ dV-. SEWAGE # ST-91_,_ VILLAGE Mhf-s40(15- t ASSESSOR'S MAP & LOTOPoj, INSTALLER'S NAME & PHONE N0.1e SEPTIC TANK CAPACITY 1030 LEACHING FACILITY:(type) `�i�Fv�c9{-� �s(7X=y NO. OF BEDROOMS 3 PRIVATE WELL OR PUBLIC; WATER_JPJ- `Wt BUILDER OR OWNER Ac�,uN Cjj_ w DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED t VARIANCE GRANTED: Yes _ No n4./A- 4g� TOWN O'V BARNSTABLE LOCATIONi07 c5'S%-7wyvT&f'ry _SEWAGE VILLAGE A MATS ASSESSOR'S MAP & LOT INSTALLER'S NAME PHONE NO.(�a C© SeQ\iC t SEPTIC TANK-CAPACITY �5QQ 6A\ LEACHING"FACILITY:67pe) -�OW �i��yS�rs (sue)G NO. OF BEDROOMS RIV. Tr s"" O PUBLIC WATER _ BUILDER OR OWNER C`C eOr CU G�c,m 11A DATE PERMIT ISSUED: `3 r l 3 - DATE .COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No +� s (r` 'FfO'IT P c C No..__$______-__ --� .............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .0u1..l.,.t...............OF . ApplirFa#ion for Dhip i al Works Tantitrnrtiun Vamit Application is hereby made for a Permit to Construct (K) or Repair ( ) an Individual Sewage Disposal System at: ...�t+1.1-ii-S-:g:i-lax L ...................... `--�-P ................................... \.1 ocation-Address or Lot No. ®frr'�1/ /1�0 L�C7/Vi'C�S`t�S� Cil/T (//C 1 .......... ............. ..... ......................................... Owner aT._... v ......................................... WiFST, 2 '! � ....tv�......? °.... Installer Address QQ qq Type of Building Size Lot___�!_C _.± ... Dwelling—No. of Bedrooms____'q....................................Expansion Attic WO) Garbage Grinder a`4 Other—T e of Building ._._____ No. of ersons______________________ Showers YP g ------•------------- P ------ ( ) — Cafeteria ( ) Otherfixtures -------------- --------------------••--------•----••.••-----------------------------------------•---------------------_-••-•------------- •••...... W Design Flow.......-S..:.........................gallons per person per day. Total daily flow...... 40.__.._______._.._....___._gallons. WSeptic Tank—Liquid capacityt5�gallons Length_10`.'f'_. Width_S�=_&`.._ Diameter________________ Depth_'5zn&.r x Disposal Trench—No.__.__I.............. Width...t�e............ Total Length...5-2 _______ Total leaching area_L.C.)._h-----sq. ft. Seepage Pit No_____________________ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box (y j Dossin tank '-' ..---._ Date---� ------- Percolation Test Results Performed by._,l� CIS w�--- - -�• ._ . ��� ..���--- Test Pit No. 1 AZ_._.._._minutes per inch Depth of Test Pit---k�.......... Depth to ground water__ gT�5,avl-0 (i Test Pit No. 2.4Zc.......minutes per inch Depth of Test Pit_.:.' l__________. Depth to ground water.......9•r.......... Q+' ••-•-----------------••-••-•••-••-•••-••------••----......------------•......._..... ------• .......... O Descri Description of Soil__�_A...._Q"6_`r._.�.S2Aw1.._.G°<_t t' 4Q�-`= )Q9`•�te iZ° Cc.d �k Cp s 4^�c-?.___`9-A�4D--------------------------------------------- - ------------ -- --___--- --- ? tw1----�" 18_'". _ -t e :C w '..� i �i�e i� _ �i�1�=--oo, U Nature of Repairs or Alterations—Answer when applicable.---'-* pplicable____: T:AL -ATION AND•-CERT......-Itd-W.......: �Er S�'STEM WAS INSTALLED IN STR:C -----•-------•---------------•-•-•--------------------------•---------------------•--•-•------...__...__.....----------------------•----------------•1.............................................. Agreement: I t A NNE TO PLAN. -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 undersigned further agrees not to place the system in - operation until a Certificate.of Compliance has been .is=U . y the board of health. Signed•• .............---=- ..................................................... Date Application Approved By------ a, ^ '� �: - -•---------------•--•---------- ..........:Z- ��---�- Date Application Disapproved for the following easons: ' 3:iiit s. '�Date's_` PermitNo......................................................... Issued......................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........... ..................OF..........T?Q;,rn;S L........._••••.............. Tutifiratr aaf &—int#fiatta THIS I _CwE'R�IFY T at the ndividual Sewage Disposal System constructed (✓� or Repaired ( ) by.......... C ---- _.:._..... ' Installer at.•----••------•---•L t....... S____•W n-I--S -- -b cxjY, alley . �CV S S (-t l tts has been installed in accordance with the provisions of 5 of-The State Sanitary Code as des • ed in the application for Disposal Works Construction Permit No..... _______-� '____-__.._.. dated......z". _............... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................................................................... No.....��::. G L« �� FEB........ ...`. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ....... �:;���...L. 4..............OF...... Allp irafion for Disposal Works Tomtrnrtion Frrutit Application is hereby made for a Permit to Construct (X� or Repair ( ) an Individual Sewage Disposal System at: ) t .............. —t' •- Location-Address or Lot No. ......................_......................._.._.......... --•-••---........-•---•-•--•-----•-...................-•----......----......••----..............-- W Owner Address Installer Address Type of Building Size Lot.... -- Dwelling—No. of Bedrooms.._..:�..................._.. .............Expansion Attic (0c) Garbage Grinder Other—T e of Building ..... No. of ersons............................ Showers a YP g ---•----•--------=---•- P ( ) — Cafeteria ( ) Other fixtures .. - --- --------- ----- ------•--------.... ... W gallons per person per.day. Total dail flow_........ gal Design Flow--------�-`'.----------------------- g P P P, „ Y '�'�(.. ....--------.......* Ions. WSeptic Tank—Liquid capacity_1_-5-. 1 allons Length__!`---G.--_. Width.._?_.: �-:a Diameter---_-__---.... Depth.s_.'O.. x Disposal Trench—No......j............. Width..... .......... Total Length__..? -:.... Total leaching area...69_5-_--sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box (ydj Dosin tank (NI _ `" Percolation Test Results Performed by..f_L—J^�..4� "'� .................................1 --___ Date._. R ,-1 Test Pit No. 1.4z__._...minutes per inch Depth of Test Pit----- __._._._... Depth to ground water...'q�.- rX4 Test Pit No. 2..Z.t-......minutes per inch Depth of Test Pit---1.1.......... Depth to ground water--------9............. ..... -- Description of•Soil--- ..' O ............................, ' t Aw 1 G 15 v > ......................1 � I. �Z• :.`<_i�� a cU��r'S ' ................ W `/_ `..... "G� ._1.;O!�4��.----�.... ti.8a ..f�?-���`�� � �a..."'-..5.�.�,s��`.�' ���--.LLEai�k((JAk� �Ac--��`aµ+ti 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 TITIZ 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issu d� by the ar�d of heat. ......... ---•---- ----•..board /...................................................� ------..._.•--•• ................................ Date ^� Application Approved By.........--611-•-- -------•---- ' 3 ------...••. Application Disapproved for the f ollowin r asons. Date --•-•-•-------------••--......--------------•---•----------•----------------------...------•---------•-------••---------------•--............--------••----------------------------------------•---..... Date PermitNo.......................................................... Issued-..................................-.................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ................/dw .......oF.. 'r •c/44. F3 /_;�:7......:.......................... Trrtif iratr of TontpliFanrr THE IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by---- a-------------------------------------------------------------------------------------------------------------------------------------- Installer has been installed in accordance with the provisions of TIT 5 of e State Sanitary Code as descr_i-1d in the application for Disposal Works Construction Permit 'o.___....ft.._!:_."�_�.............. dated__...__. ......................(_.._..... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM.WILL FUNCTION SATISFACTORY. DATE........... Inspector..................................................................................... M1 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH / •}�G.0 `3 1 OF....................... —No..................••`..-• FEE...... ...�.�.. Disposal Works Tonitrndion runtit Permission is hereby granted.....�e` 63W._.......A� 0 to Construct ( vT or Repair ( ) an Individual Sewage Disposal Slit at No----------------------------111-4 .....(--6 .--.../��� GC. r� �! ..../ fiJP%d/!S'..... Street I as shown on the application for Disposal Works Construction (Permit No........ l Dated..... .... ..............�..._.... _,_ \I---------••---------- -------•------.---------------------------- _ d of Health DATE....................... Boar FORM 1255 HOBBS & WARREN, INC., PUBLISHERS . � 3Z � �NLsr TZ L�_ c� Al Ilk J Lov�z c.)� I - y y I T�j�s 9z \ 0 i A ik�, 1, %s 4-0 ti Q;l f3� 1 't ld Av rid � \/ i \c •., / � �/ Y .1`1i1 Oh ,.,���'v %� � •i•"� C.r_i ii i.:,vr�;c �i Qr�7�•i:F�/ '' � J..,vim, ..--�,\J,-�?f .��.�L• 14 1,i� tY•. �A ,,� �{ n 1✓� � L 1:1 1 � i��� � ,� � i ►D E s-I 6-Q -DI LTA ---_ SINGLE. FAMIL`{ l3�RooMS - � � SEA .gTl/•�C�IC 7 Nc• C-P,,V-ZAGE GRIrJOEiZ, Ail G. D A\LY F•Lo,n/ = 4 x 110 4h0 G.P. 0. S�-IC T SEPTIC. 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I , i eo / f i 011L >Z vv ' / y OF '� S-•U '� ,Ott � J � ;t. ) ✓ -Y' n�r� '--` l i`,r n�"��✓ � �.5 tom. ,._ ._.. .._.______.....-------_'---- �h_l I I c r DEsr,6xN -DATA . SINGLE FAMI1.:.`( - ,c� L3E01ZooMS � SCE yT%/-�CyC-�, N o G-A R.8 AGE G RI►J OE[L.. AJ Cr. O AX LY F Loin/ = 4 & 110 ° 4 40 G P. 0 S�7/CC 7- 5EPTI C. TAQte- ` 4q0 s, I Sol &40 G. P. O. U 5 E 15-+o GA L SEPT l C. TAfJ K, .� f JA of '„as I s Lo - V S E (o FLoW t>11=FWSIJR.S �. r 5`` o s917 HAR. w, S►DEvq/lll. A1A vj<o S. F. cs R1 C D filar A. u S'IVAN ti�'6 Z4O 6- P. D. a o BA;:TER P;o. 29733 BoTTol`( AZEA F• ''. `• O /�=� �, "F� l.o (,O Si z G, P. b ToZ-'AL SIGN - 75?., G.P. 0, sit U�' a PF2caoc.AroAj RATE = i "IN z M,N:ak-cuss 9E'TAIL op 01SPoSAL ge7D t�oT>GS EL�IATC u o•.�� Si:!> ,J 3Z' —_A a a o/z r piED Pl0 PC A EI -� LocA-Ft o A7 M q R_&7oos- M,LG SCA LE I'►� o' DHT'E i /13187 101,FFvs012S �,� "+Al9ST supEriVIS 1/30/V7 r:SIGN"PSG ENG1 ,_E. . .STALi_ATION ANIJ ���, a - E SYSTEM WAS INSLo"-T G6i�c�'! STRIC BAXTE+2 NYC, =NC. Y G�RTI FY THAT THE P,Zo►�ot,60 bVJI:LwA)& •5,YowAl I�EGISTERCD Lrq►J Q Su�vCYo�S NE2Go,v CotYMYS vviri4 THE 51DELJWF .9uo osT�zv"LL.c ^ MASS 5ET6AUL P_MQuI R-E MGrNTS o F THE T-6W tit ApPL.I C-AKT M cV EC" (:�_US-Tv� r uP ?.AV-0 STA gLE AN50 %S NoT LcCATtz 17 ,�Qc A►►V TNC FLoco PLAan] . T1+/5 PCA;l1 ,s ti/oT T3ASCr� ctii !#,v iA1sTk - V/`9E^/T 5u-VCR/ A►JD TNL or-1�SGTS Io z 8 85' Rj� -5"o wn/ �f�C=a&J 5Ho u4,b A'u T /tee USA ToPoFFaD TT C-S-rA8L.�5i4 LoT — CL. 44.5' I=C-- 43.11t T`EsT Ho LE P• 46 34 61 13�SS 77rT ri; i . �� -,-,—X 7rf�� Fir 43./'t 41,g Lf 5 W Et l -SSW 2.53 INV. I 5w IWvA flIST, MI J— C yo,3 S, q l,9 q I l CrA L• 91.5 -m:3 $OIL s�PfC. INV. CLC c TAOY- ((o) 47C`�' P-to�,.� o"FFusotts coAizSe wrTH 4' cF wAsHtD ANv 2 STc rJE A LL A R-ov r�0 w fi•1 I Z o P M en> r PROFILE vi- PROPO 5c—D wasNlD PC-g6r k_1E 00 -ro P I �7 6EW AUE ML-D> Sq,jp tr!ISTrn16 w�?L!Z L-L-31.5" i _