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HomeMy WebLinkAbout0046 WHITE MOSS DRIVE - Health 46 WHITE MOSS;,MARSTONS MILLS A= 031 006.004 f r ATLANTIC ENVIROMENTAL P.O.Box 2384 � i Mashpee,Ma. 02649 Attn: Commonwealth of Massachusetts Date: 11/13/95 Town of Barnstable Board of Health 367 Main Street Hyannis MA 02601 From : Mr Michael DeDecko Po Box 2384 Mashpee MA 02649 0V Dear,Board of Health Official; I certify that I have personnally inspected the sewage disposal system at the following adress : 46,White Moss Drive -Marstons Mills, Mass. The information reported is true,Accurate and complete as of the time of the inspection. I have not found any information which indicates that the system fails to adequately protect the public health or the Environment. If you have any questions regarding this inspection,.please contact me at this number: (508)477-14-20. Thank you. I Sincerely, G , Ichael DeDec o phone(508)477-1420 4 j Commonwealth of Massachusetts 410t, Executive of E nvironmental Af f airs 1 DEP 799 Department of Environmental Protection s , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: y e u, ;;r� Ness'tea-. . �-'l+ -bra► r'�, \s,N1A . Address of Owner: H6T: C-sVro (if different) Date of Inspection: `C�\gs Name of Inspector: ",L rtCompany Name, Address and Telephone number: Z 7?d cx Z3$y� �As�Qes_� 'Ma, alb�`� So& unZ-X`i2 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 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 . Passes .... Conditionally Passes .... Needs further evaluation by the local Approving Authority .... Fails Inspector ' s Signature. Date: p` The system Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office or the Department of Environmental Protection. The original should be sent to the system owner and copy sent to the buyer,if applicable and the approving authority. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Adress : �hT� l�'1dss�_,�Aal� Owners : Date of Inspection: k\A q,` INSPECTION SUMMARY: Check A,B,C, or D A) SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CM 15.303. Any failure criteria not evaluated are indicated below B) SYSTEM CONDITIONALLY PASSES: -•-- One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determinate (Y,N,or ND). Describe basis of determination in all instances. If"not determinated", explain why not. ---- The septic tank is metal, 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. -•-- Sewage backup or breakout or high 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 if (with approval of the Board of Health). ------ broken pipe(s) are replaced --- obstruction is removed ----- distribution box is levelled or replaced ---- The system required pumping more than four 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. I ' ----- obstruction is removed SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Adress : Owner : 1�0►�`�� Gr �lo 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 de- termine if the system is failing to protect the public health , safety and the environ- ment. 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 within 50 feet of a surface of water ' ---- Cesspool or privy within 50 feet of a bordering vegetated wetland or a small marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNC- TIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT. ---- The system has a septic tank and soil absorption system and 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 is within a Zone I of a public water supply well. ---- The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. ---- The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analy- sis 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 notrogen is equal to or less than 5 ppm. D) SYSTEM FAILS: -- I have determined that the system violates one or more of the following failure criteria as defined in 310 CM 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to cor- rect the failure. ---- Backup of sewage into facility or system component due to an overloaded or or clogged SAS or cesspool. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) PropertyAdress: t{�D f- taoss Owner: Date of Inspection: D)SYS T E M FAI LS (continued) --- 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 over- loaded 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 Absortion System, cesspool or privy is below the high groundwater elevation. --- Any portion of cesspool or privy is within 100 feet of a surface water supply ortributary 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 50 feet from a private water supply well with no acceptable water quality ana- lysis. 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. i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) PropertyAdress: ` (, 4J�, �\oss�2., a si �•i\S Owner: Date of Inspection s E) LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above :. The design flow of system is 10,000 gpd or greater Large System and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist : --- 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 supply --- the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area - IWPA)or a mapped Zone I I of a public water supply well. The owner or operator of any such system shall bring the system and facility into full compli- ance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please, consult the local regional office of the Department for further information. .. i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST PropertyAdress: 4(, Owner: tlo►J�� ��\vc� Date of Inspection: Check if the following have been done : -xPumping information was requested of the owner ,occupant and Board of Health. Y- None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during the 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. -X The facility or dwelling was inspected for signs of sewage back-up. - 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. - The septic tank manholes were uncovered,opened and the interior of the sep- tic tank was inspected for conditions of baffles or tees,material of conskruc- tion, dimensions, depth of liquid, depth of sludge,depth of scum. The size and location of the Soil Absorption System on the site has been deter- mined based on existing information or approximated by non-intrusive methods The facility occupants if different from owner were provided with information on the proper maintenance of Subsurface Disposal System. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Adress: �6 Owner: CG-,`vo . D ate of I nspection: k 1� IQ� RESIDENTIAL: Design flow : 33 o gallons Number of bedrooms : 03 Number of current residents: e.z Garbage grinder (yes or no) : uc� Laundry connected to system(yes or no): %��s Seasonal use(yes or no) : vz-.,v Water meter readings, if available: Last date of occupancy: COMM ERCIALIINDUSTRIAL: Type of establishment: Design flow : gallons/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 RECORD ands urce of information: ................... System pumped as part of inspection(yes or no) :..No......... if yes, volume pomped: .................... gallons i Reasonfor pumping:............................................................................................................ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Adress: q� &tl Owner: o�T� Date of inspection: 1 l�5`SS 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)and source of information nc it p ...1 g81 Sewage odors detected when arriving at the site : (yes or no)....+tea.. "`�� SEPTIC TANK : ...')' ........ (locate on site plan) Depth below grade: .... '.. Material of construction: ...Y, concrete ......... metal ........ FRP ........ other (explain) ............................... ....................................................................... Dimensions: .5X$.?..s Sludge depth : .......... k tee r baffle:.......Zi?................... Distance from to of sludge to bottom of outlet e o R 9 Scum thickness . . .................. i . Distance from top of scum to top of outlet tee or baffle: .....1Ca 1.0............................ Distance from bottom of scum to bottom of outlet tee or baffle :...1'A................... Comments : (recommandation for pumping , condition of inlet and outlet tees or baffles, depth of liquid I vel in relation to outlet invert,structural integrity, evidence of leakage,etc.)..Na..t�aca.. . ��Cl!?.lf�.�4.�1�..�.....�t,� .Q:G`u�loY4?.'�4. �?.�,�•S�'..,�'...,�,�9e.�.S\'�i,�4:TR!!��...1N�4,t�� aw S'aw�ep� iJo £Ji�,,..c�..`� GREASE TRAP: ............... (locate on site plan) Depth below grade: ........... Material of construction: ......... concrete.......... metal ..........FRP..........other(explain)... i ................................................................................................................................................ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Adress: k-bss Owner: Date of inspection: GREASE TRAP (continued) : Dimensions:............................... Scum thickness:........................ Distance from top of scum to top of outlet tee or baffle:....................................... Distance from bottom scum to bottom of outlet tee or baffle:............................... r� Comments: (Recommandation 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.)........................ ................................................................................................................................................ ................................................................................................................................................ TIGHT OR HOLDING TANKS:.............. (locate on site plan) Depth below grade:............... Material of construction:........concrete........metal.........FRP..........other (explain).......... ................................................................................................................................... Dimensions:............................ Capacity:....................gallons Design flow:...............gallons/day Alarm level:............................. Comments: (condition of inlet tee, condition of alarm and float switches, etc.) ................................................................................................................................................ ........................................................................................................................................ DISTRIBUTION BOX.. ... (locate on site plan) Depth of liquid level above outlet invert:...�.� Comment: (note if level and distribution y1jual.evidence f solids carryover,evidence of leakage into or out of box, ekc.)� �,?�,Q..,....taQ.. s i . ............................................................................................................................................... SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Adress: "l ¢. Owner: Date of inspection: k4`5 S PUMP CHAMBER:.............. (locate on the site) Pumps in working order: (yes or no)............... Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.).................... r ................................................................................................................................................ ................................................................................................................................................ 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: leaching pits, number: ......I........... leaching chambers, number:........ leaching galleries, 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, CESSPOOLS:.............. (locate on site plan) Number and configuration: .................................... Depth-top of liquid to inlet invert: Depth of solids layer: .............. ............................. Depth of scum.layer: ............................................... SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PAR T C SYSTEM INFORMATION (continued) Property Adress: �k(oOwner: Date of inspection: CESSPOOLS (continued) Dimensions of cesspool: ...................... Materials of construction: ..................... Indicator of ground water: .................... 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: ............... (locate on the site) Material of construction: ................................... Dimensions: ...................... Depth of solids: ................ Comments: (note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.) . i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Pro ert Adress : Owner: ►�t-� Cc� Date of inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate at' wells within 100'. 4� 11>t, Mv►a�" s �1,\1S y 02 b DEPTH TO GROUNDWATER: Depth to groundwater: 5,�-.b0.feet Method of determination or approximatirre: e..:�.C-�p.�c�la�►.c.�...s4.¢,v.e.:�.`:�.. 11f`�V4,S / 01` ,4... r�... A�..f4 �i...4.�MN�.. .'?F..��. .�lCl..� J►1N4 .4�? �`g,,...1r, .a.TTtaiv P`6L� TOWN OF BARNSTABLE LOCATION �O . �In"� W1o55 0 \,t SEWAGE # VILLAGE tM a c 9�—'s MA 5 ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY O y a y 1ld�s LEACHING FACILITY:(type) U�cA, (size) (o NO. OF BEDROOMS PRIVATE WELL O PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COLIPLIANCE ISSUED: �I_ f — 7 VARIANCE GRANTED: Yes No / . Al 1 Lo 's ASSESSORS MAP NO: 3 / 7- PARCEL NO.- Fizz 7,.1 THE COMMONWEALTH OF MASSACHUSETTS BOAR® O H EA TH OF........ec��. .-------------- - - ApplirFation for Bi-giooFal Workii Tontrurtion ramit Application is hereby made for a Permit to Construct (L-<or Repair ( ) an Individual Sewage Disposal Syst Location- dress o�of No. n... .r..�:........ ._ p----------------------- ---- --X....___... 1 .....` . YY . .. ..�i: ._-� Owner Addresg Installer Address d Type of Building Size Lot XA 4'-----_Sq. feet V Dwelling—No. of Bedrooms.......... Expansion Attic �� Garbage Grinder k7 C> ►i A4 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fiur W Design Flow........... .............................gallons per person per day. Total daily flow-------Z.................................gallons. 9 Septic Tank—Liquid capacity allons Length................ Width................ Diameter---------------- Depth................ Disposal Trench—No--------------------- Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No_____________________ Diameter.................... Depth below inlet.................... Total leaching area..................sq. it. z Other Distribution box ( ) Dosin tank ( Percolation Test Results Performed by.__....... �1.:. . . ate..... .. ,.._.._._. Test Pit No. �� inutes per inch Depth' of Test Yit.__. . Depth 5 round water.._ (i Test Pit No.�04 .minutes per inch Depth of Test Pit......... Depth to ground water...-- - p _ r M:Q..1 Soil . . x Description of Soil.... ` f .. � IL .mot _ - � ----------------------------------------------------- - ------------------------------------------------- W ----------------------------------- -- ..... •• ...... . -----.....--------------------.--....-------------------•--------------------------------------------------...... U Nature of Repairs or Alterations—Answer when applicable--------------------------------------------___________-_--___-.__-•-----------------------___. ----------------------------------------------------------•------------------------...............--•-•---------------••-----------------------------------------------------••--••-•-•-•------••---•-• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with tze provisions of 1i of the State Sanitary Code— The undersigned further agrees not to place th system in operation until a Certificate of Compliance has bee sued by the and of 1, Signed---- - -----• - -- - ----- •- ..........................�...-- ----------- -------- ,. ApplicationApproved By------ --- - ----------------------•-------------•---•--- ....................Da--------•-------- Date Application Disapproved for the following reasons--------------------------------------------------------------------------------•------•----•••--•............_ -•-----------•-------•--•--------•-•----------------------------•-------------------.........----•-......----------------------- --------------------------------------- ------------- ----------------- Date PermitNo.... ' �•.................. Issued..------.........--•------•--............-----•-------- Date - ' ,7. ,..,�.� .�, Yea r•'�.�, i lKtt �vN E" LoT EG"T74N ,�: T�'�F "U� 4 Q " �n �. 5 }./ a 'T7 R r• GLUS : O N'1CJV�. �1t 1 R 30�r5'f.�S SETrzzv K } . j h sly .7,n. r^ ^+1 t wX 4 _ ZS / 27 It + r S '�„ „(„� 5 � - 1 � ° l�/'I"; ! � N.r.� � 5 '",E I � '.' r �• � 4. r # ",r+.kf����3�� „,�Y i y y �1 /`r 7. 0'Y 7 r Z �• r y i:+ y#s d kar$ 4 ••tt 7} r vA t: :�..,* � O f `f �� 1 o v`t�$ i �' '•r' t.'• ` .��' � I W - '` t� :r ��.rbggs' y _n' x':. .. � s� _ N r.h fs�i� d �,��' z. } .'* i .. ; c .t '. +,. / + " ..� • �is s c y a t.b R. �'` .Fs, ,iY pi X q„ +�' ..,og-�yK ��?"r" ':r G - �9 �•. a •'f'tR .rl �#rs _4�r�f� r ;•. � I, 3. �` •Q tit"' r * t ��/ r^t _'h �'i� � ry�p's��i'�z'e5��' .&" t _ T# .r �m/•\,/.• x '• ' .r J •,-, I\ s�+ �r`� „» p� ,� x sy-t s�-K'ii` t /4. F r Q 1 •i x yt tE 5•x��,�,�, €� \:. �0JA � ` `O- ; \ R -_. Y 2'f+�r.y'?•k {,1 t�lrlf ,tyr� /-v Le"7,,' Ll P. V�- z I CERTIFY THAT. THIE PROPOSED `®UILDINe" �/ . 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MR� 4 'r AESISH CRf7'EMlA ssAc /.� ®/�*/.-NSI®a _FT 4 r 1,s }+ {r•"�N"t a 1 ,. s .' Iv�1i�79E/'6 ®�'BE®RO��ks - - .. - - � aAGA A.P/✓PosAL t/N/r Nol SOIL LOG 6 ` 4 TOT•�L .�.�P1NJ�7"E.O PZo`v 33 O 0,4�/®,a�+- s0/L O/L r�ST / S T.�ST2 ®/L } � MUr%'fdER Owc 40ACRIMr. f�'/TS /^LrLLsY. 1, oZ ELFY! 0AT� Off" S®/L TEST {�2'L�86 SIDE&C HG PEJ4 P/T P7; Ir ✓ _ o�-7J ny�o/cr RESULTS PV!T/VE�'ED dY TbM 1�le'K.eA "•w r* f �OTI CH/NCr PAR P/T .PT. PEI�C®Ld'T%OiV /@e�TE / <2 !y/ /NCI 5 SU�I SOIL ',l '�Y M a r rat t��'�" £.�:r•� :.�, 'u✓ s ',;,•�} ";.w,r r_ = a<., -S'O-- /�GS'oNi R_ T4-7 EERCOLA7TOTAL LE4CH/ YG AREA QE5ERYELEACNhYCr 4/PEA S4. FT S!�T - c(2 y 4_6 ;L M _ r. WID'PP. 9 3 a'';.,:zf rc c�n;3 s�, :, .< r v. nt .,,�.t• !c .,,. _,—_ —_`. - - 2.0.. :�.• :l .MA t - n.?z� RANO ��'Z e S .. ,., ^ 1 , War _ ,.� ... .r ., .• .... .. .. r .Nr:'x ;�..: ___.-._._.. - - --�— - F.iwE 5FIN0, air, O/G �. r [ T ..�1,.� !9.. LE- • a y .Y�i'' r.r r^.,,c..........:, ,Y'',a.r:'..! a -i. .„.fi.,7r^. .d .�. r+k'.K,¢-".. . ',......�, _..,.. i..,_,.r'#.•:_'+'...<-..z`T.n.>_:y,....,+,_,. -,,..�N J....�-,r,i_,am,.,,.S,x.-.:w.... :;,...u..:. _4_.-,.t.-dS,...-�..... s�-. rx+ !a'�=::.-...a r• � ,. ,,:. .,.,....d.r..,-,.atwE.,..,,N. f ? LEVY , _ A�. .. i .. _. ... '. ��^ .� .�. �...«,,.}'" _,, .. 1, ., r . �< �; K,. >..,, t a tF_. .:..« <_ . :, „�r •�. ,..<. � USETTS �ACH _,.wT� ��,,✓. r., :.. �_ "?. .r+ �� ._ •.t e,....�.,.. ,.. fs ,. .«� . .�. �, {f� ,,, ; .�o,NS R _! t'�a,. � t 9 WEST.MAIN ST_ TEAVILLE'MASS �: .,_ ... ., . ,., "'^. _. _... e.t d a.. ,_'r' .s . .,n. .�,. . :��'�s. . Sx- .� �w.>:, i�,: <a ..F• >x.: 'i''.7:'' 88 BEET '=CEt+1 +:'a. ,. .Fy},. .t✓d. n:. ... :n✓.... +'r.. �.•. . ..r-Lt. .,.,..9'- ..... ,. i.. -...f �e+`.,F -n 4 :.,..,,. :. - "h, C ,rs' +' K.'Aa ...�. , ,..' 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':•c ..... .. ..w.e 3"*.�. .. `+.G .�"� r• ''� .-a• - .y t• .,,J .-Js t,.: 5s_a. ,,. sSPR°"r.v_k.,'r.S _ ',', '....,.... - J '. '•"tr.- `4g. W., -•9'' _.1. d< ,ram. , . _ � . ,�. .:��•._ - . tog—,, `TT�'yY, ..t ... .x,...y�ly.• ...e_,. .{V: k"� ,g, -7'. '�'.. Y-�- "x'",. .�' �n V,6/ 6Gr' ":�`.-w.t_: _ +3<r� -x:tCl sYd�.. ... ....,, z' " w-r.. ""F. ��:' .*" r-�..'�xx,,�, n •i.,^ ,.Y'� py}) , �i •Y�'' {+� •'h?3'., �;as r.w .�',� t, �' �' .,6. �•` �,.~ .q ,y„ ,pig ,..s 3` ✓��;.��".��"�Lfi� •..!4_...2 art"- • 4"",��. Y 'ra It .:c.. �.x. '� <. •K' • .r.:,•tr- rcc JG:.,t-.. � K�r.C�.`n�' ��-,.+3 w � .,�. .' u;':4'��...+ Y'Y :7��, Y. t�F..: L'1`Sx i.Aa , y ' .... .. -cP9' .. .�-i -. -- .- ,. s: i�' s'.�.$'q��:�"�Js. tp ., '�. -. ti{ :. �. : y. { ..3„ ^a` t.e- a.•.'<�°.x e+ o?ti++s .,'"�,,.' >a t ... �.�vs$i..y v..,,rd+�a... S'w •.+ - .' .: -.. .. k , yr �� ,,,�'',�y$$ii__ ...�1`� a...;a, .,r.�<...s �� - ,; �4, ,v, w_ v�ar��k`''.�. .,,-/ .+3'��yF:.!Y:.w�n•" �'�t4.:�'r_ _ �fi .ssot� .+t", 4}�N'.r�•r +x..���. -3 :�� '�....,_.- ..}.'����+�'l�i^� rt� , - THE COMMONWEALTH OF MASSACHUSETTS --~ BOARD OF HEP �TH :. ApplirFation for Elispas ai Workii Tongtratrtion Frrutit Application is hereby made for a Permit to Construct O or Repair ( ) an Individual Sewage Disposal ................... ...... .... .. 41 AX��;;;;-------- Location dress ^"m^w Lot No Owrer AddrAs --- Instal-er Address .c U Type of Building . Size L _ _....... Sq. feet a Dwelling—No. of Bedrooms_______R.,a________________________________Expansion Attic Me) Garbage GrinderPQ pa. Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) P-4 Other fi_xtu es •---•-------•-•---••----•............................................................... W Design Flow.......... per person per day. Total daily flow___._<. _ ._____.________________._____gallons. 9 Septic Tank—Liquid capacit ;gallons Length................ Width................ Diameter................ Depth................ Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area_._.................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosm tank• ( P. Percolation Test Results Performed by _ ' ...............:s....{.....n __- 1.4 Test Pit i�o. l pinutes per inch Depth of Test it _r_____ Depth o ground water.- - . f=, Test Pit No,.,2 � minutes per inch Depth of Test Pit _______________ Depth to ground wate ✓ ,_... , r-------------------------------------___________________________•-•--•----••--••--•---------- 3e O Description of Soil . �- "� __ -----•----•--•-----•-•--- W .................................. •-•--••••••-----•------- ----- fd --------------------------------------------------------------•------------•---------•--•-------- •----•-----•. ---------- -� ._._ ... j�_: 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 IT LE E ;of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has beerissued by theme board of heajlth: try' , j { Signed .; u �'' .......... ............_.... Date ApplicationApproved By.................................................................................................. ........................................ Date Application Disapproved for the following reasons_____________________________________________•____________._......_______________________.___,__________......._ ---------------------------------•---............................----•----•------------...-----•-•------•-•-•---------------------•-•-•---•--•--•---•----•--•---------•-----------•-••--•-•------..._ Date PermitNo.- ".. ...................- Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HE TH Qlrrtifirate- of Tuntph anrr THIS IS TO GRTIFY, That the Individual Sewage Disposal System constructed �,�or Repaired ( } byvv, = ..............p� ...................................................... ---- -••-•----•---------•------•----___------•----------___-•------------- at ......................~ it�.1lf O '�� _ air er / T.e� has been installed in accordance with the provisions of Ti i T i j of The State Sanitary Code as described in the application for Disposal Works Construction Permit No...8_7.....;Z.Vr,0'_........ dated_..-------___................................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE SYSTEM WILL FUNCTION SATISFACTORY. DATE.......................................•----•---•••-•••-••••-•---...--••••-_.... Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEA TH .......�! ��............oF.-_ ._ _„" FEE 12---" . 13bVagat Work' Tono#r irrn rrmt s Permission is ereby granted_._: - t!Y......................'•. .,_.. ................ •-••- ..................................... to Con uc (-r4) r it ( . ) an I ivldu Sew sal System ZL O ct_3 ....e4 •----•--- Street as shown on the application for Disposal `Forks Construction Permit Nq<2_11 .... Dat^ed.......................................... .......... - ...... -•--------------•--•------•-------••- Board of Healt DATE................................................................................ FORM 1255 HOBBS & WARREN. INC., PUBLISHERS - ti t , k Y, V�lv �� - .,. :.. ;- i� • i� a Ls r�afi� b t k k ' rW��Y LOT R2,a-n �1 td /SD �! r-�®N'r";% CrF C �(/� SE i I�..s --> 3o�rs/i S /�( A�� (Mnc ✓/O�s , s �s y AMA!✓ L� t i{&�4 iT �r.< .�. mg '".iSgeyi �11I�1 i !y` 5P'f,,ia ,-✓ s x z i V uE- rt � ►D� + fiF y137 ` TI IM lb Aj �tqu r IYF� ZL�G �- jjr `VVV d At Zo- \� �� `. l•. �' .���/iyg'�',[q g:i .4. ��ik phi � (E ot."V'\ �' ` i' JC�1 `V� _ �'•�4 �` rv-` t t -:; ewe i't. P„i K5 FFf - IJ CERTIFY THAT THE ,:PROPOSED BUILDING, SHOWN ON THIS PLAID CONFORMS TO ..THE LEGEND I�G LAWS QF P /�, s MA. y x DATE is :s y EXISTING SPOT ELEVATION 0 r� 3 PROPOSED SPOT EXISTING CONTOUR PROPOSED ,CONTOUR 0 a� DAVID P �. "PAt1l A. NOTE: THE LOCATION OF,ANY UNDERGROUND MARfANO j , v LEVY La a, .SEWERAGE WELLS OR OTHER UTIUTIES SHOWN ON �� c�vi� + No. 1a617 THIS PLANTS APPROXIMATE ONLY AS DETERMINED .09 No.31115 �^ FROM RECORDS AND/OR VERBAL INFORMATION �'�� `��� �� R�.� ' -- ��✓�:L THE CONTRACTOR IS RESPONSIBLE FOR THE Sr� y .VERIFICATION OF THE EXISTING LOCATIONS IN � � THE FIELD. N LEVY � ELDREDGE ASSOCIATES, C.LIENT6 E I9 ` ENGINEERS—.LANDSCAPE ARCHITECTS JOS 'NO. '; � ' ',PLANNER$ LAND SURVEYORS f�"�s`M0—s "ARV s r L . 809 WEST MAIN STREET Ma J' CHKO..BY$ ` ';3; i M >' CEIVTERVILLE, NIA. 0263 2 , SHE T �. E! DATA77 } r: , E .... 4aF`2; r SCALE! } 77,77777 .J ;.4a k A,+d. r...??ru...l°:ki7.af.`G&�a' i'W.rzla?.ws°,� i.i..d.P3?.::-.sai-..fsco+. "x,'.f'tn��''.!f:-�x..ar �., a,u k VN,—, ' - - ------- ------ ------- ji -Wq -add A^er Z4"A01AA1,F74vR COty .00 A CA� 4 vc. H,--,4VY CA 57 SAl,-q 4 4� BE S —.0 OTCAf 10V oP* 5-7 2 t4liv. o,--COlvCle-L CIO KF'o"Ir so 4; CL,--AAI -TANI0 &ACk 4'. LAYER ma jw tc,c OAZ;�� A crop 49 WA SHeV sm--yz rs 8 64 fit, 3 PRECA57 S.-ji6A6,- -pir,c JV ......... /m VE)TT' AT &1///-1) MC." C,(54EW rAO&I-A 77 OA�> SEPTIC /IVY -r JPA-P77C 7,-4AO'K FZ LIJAdt4 -r 40.157RIADV7101y BOX N X 97,O� FT GRO"NO W,4rEM 7ABL -T-a:,c I ION 0 FX. 7AOULATIOM LEACHAIV46; 10/7, I 0Af XT 4CA 4L Z' DAF516H CRITEXIA 1a14 a FT. OF&-Xr1fX1roo1vs GA ROA G.,E P/5.-':PO-';,4 L UN.,r AJOAL�F- so//- Loa- .510/1- 7-0,57 7-0 7A Z e,:XrfAe1A7---t> .1=1-0 AV 33 0 0,44.1,PAY- -SO 4 TEST 0/. SI014 7--ArS7-10,? NUMOPER OFZ.-54CMINZ; .4P/75 -7E OP- SOIL rjE-Sr 1?12 2- 51-Z>Z-4Z-ACA41A41.0 .X-E,RPI7- 151 4V. -;r. RE5uArs -r Av1vzsS--& BY 7-A4 460 r7r01W 1.64CHIN&)VIER P/r 1/3 SQ. A7. Soo s-1L. 7-07AL 4Z4CH1W4-r AREA s4p. 'Irr. �-- &A1AAA 4 4eZA-004LA 0,V RA7-,E Ik 2 r RSZFRVE LP-,4CW1A'15 AREA SQ. F 7. e-L W �A p DAVID Z egg Yz-14 -Z NIARIAND SAND 31, 08 cl VIL No. Ill O�5 r", LOT &)1-1172= 4DRl 4 L/:—1 -D LL—: WI 4, A A LEVY & ELDREDGE ASSOCIATES. INC. N, 889 WEST MAIN STREET_CENTERVILLE,MASSACHUSETTS 02632 AP,47 A�GHQ uovo,.'w.4 7--4, JOB wo. 4!9� J 7�71 k.