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Home My WebLink About0289 MAPLE STREET - Health 289 MAPLE ST., W.BARNSTABLE A= P� e CERTIFICATE OF ANALYSIS Page: 1 �';e Barnstable County Health Laboratory Report Prepared For: Report Dated: 5/9/2008 Kim Pola Order No.: G0846094 289 Maple Street West Barnstable, MA 02668 Laboratory ID#: 0846094-01 Description: Water-Drinking Water 1 Sample 4: Sampling Location: 289 Maple St,W.Barnsta-tile;IVIA� Collected: 5/7/2008 ..,-....�...x. Collected by: M.Pickering Received: 5/7/2008 Routine +Ammonia ITEM RESULT UNITS RL MCL Method# Tested Ammonia ND mg/L 0.20 EPA 350.1 M 5/7/2008 Nitrate as Nitrogen 1.3 mg/L 0.10 10 EPA 300.0 5/7/2008 Copper 0.42 mg/L 0.10 1.3 SM 31 I I B 5/7/2008 Iron ND mg/L. 0.10 0.3 SM 31 1 1 B 5/7/2008 Sodium I mg/L 1.0 20 SM 31 1 1 B 5/7/2008 Total Coliform Absent P/A 0 0 SM9223 5/7/2008 Conductance 160 umohs/cm 2.0 EPA 120.1 5/7/2008 pH 7.0 pH-units 0 SM 4500 H-B 5/7/2008 Water.san:ple,ineets tlre-reconunended limits for dr`uzkmg water ofall the'abovedested parameters.^ Approved By: ------ —�------� (Lab ctor) (,,w3 Y t ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO,Box 427, Barnstable, MA 02630 Ph: 508-375-6605 CERTIFICATE OF ANALYSIS Page: , J 7' •1O 9 j.` Barnstable County Health Laboratory 9Sr�Cii�,S� Report Prepared For: Report Dated: 5/9/2008 Kim Pola Order No.: G0846094 289 Maple Street West Barnstable, MA 02668 Laboratory ID#: 0846094-01 Description: Water-Drinking Water Sample#: Sampling Location: 289 Maple St.W.Barnstable,MA Collected: 5/7/2008 Collected by: M.Pickering Received: 5/7/2008 EPA 524.2- Volatile Organics by GC/MS ITEM RESULT UNITS RL MCL Method# Analyst Tested Note Dichlorodifluoromethane ND ug/L 0.50 EPA 524.2 yn 5/7/2008 Chloromethane ND ug/L 0.50 EPA 524.2 yn 5/7/2008 Vinyl chloride ND ug/L 0.50 2.0 EPA 524.2 yn 5/7/2008 Bromomethane ND ug/L 0.50 EPA 524.2 yn 5/7!2008 1,1,1,2-Tetrachloroethane ND ug/L 0.50 EPA 524.2 yn 5/7/2008 1,1,1-Trichloroethane ND ug/L 0.50 200 EPA 524.2 yn 5/7/2008 1,1,2,2-Tetrachloroethane ND ug/L 0.50 EPA 524.2 yn 5/7/2008 1,1,2-Trichloroethane ND ug/L 0.50 5.0 EPA 524.2 yn 5/7/2008 1,1-Dichloroethane ND ug/L 0.50 EPA 524.2 yn 5/7/2008 1,1-Dichloroethene ND ug/L 0.50 7.0 EPA 524.2 yn 5/7/2008 IJ-Dichloropropene ND ug/L 0.50 EPA 524.2 yn 5/7/2008 1,2,3-Trichlorobenzene ND ug/L 0.50 EPA 524.2 yn 5/7/2008 1,2,3-Trichloropropane ND ug/L 0.50 EPA 524.2 yn 5/7/2008 1,2,4-Trichlorobenzene ND ug/L 0.50 70 EPA 524.2 yn 5/7/2008 1,2,4-Trimethylbenzene ND ug/L 0.50 EPA 524.2 yn 5/7/2008 1,2-Dibromo-3-chloropropane ND ug/L 0.50 EPA 524.2 yn 5/7/2008 1,2-Dibromoethane(EDB) ND ug/L 0.50 EPA 524.2 yn 5/7/2008 1,2-Dichlorobenzene ND ug/L 0.50 600 EPA 524.2 yn 5/7/2008 1.,2-Dichloroethane ND ug/L 0.50 5.0 EPA 524.2 yn 5/7/2008 1,2-Dichloropropane ND ug/L 0.50 EPA 524.2 yn 5/7/2008 1.3,5-Trimethylbenzene ND ug/L 0.50 EPA 524.2 yn 5/7/2008 1,3-Dichlorobenzene ND ug/L 0.50 EPA 524.2 yn 5/7/2008 1,3-Dichloropropane ND ug/L 0.50 EPA 524.2 yn 5/7/2008 1,4-'Dichlorobenzene ND ug/L 0.50 5.0 EPA 524.2 yn 5/7/2008 2,2-Dichloropropane ND ug/L 0.50 EPA 524.2 yn 5/7/2008 2-Chlorotoluene ND ug/L 0.50 EPA 524.2 yn 5/7/2008 4-Chlorotoluene ND ug/L 0,50 EPA 524.2 yn 5/7/2008 Benzene ND ug''L 0.50 5.0 EP.'1524.2 yn 5/7/2008 Bromobenzene ND ug/L 0.50 EPA 52.4.2 yn 5/7/2008 Bromochloromethane ND ug/L 0.50 EPA 524.2 yn. 5/7/2008 Bromodichloromethane ND ug/L 0.50 EPA 524.2 yn 5/7/2008 Br6moform ND ug/L 0.50 EPA.524.2 yn 5/7/2008 ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO, Box 427, Barnstable, MA 02630 Ph: 508-375-6605 OE..!j'./7:�.._, CERTIFICATE OF ANALYSIS Page: 2 �a ID ' Barnstable County Health Laboratory Report Prepared For: Report Dated: 5/9/2008 Kim Pola Order No.: G0846094 289 Maple Street West Barnstable, MA 02668 Laboratory ID 9: 0846094-01 Description: Water-Drinking Water Sample 4: Sampling Location: 289 Maple St.W.Barnstable,MA Collected: 5/7/2008 Collected by: M.Pickering Received: 5/7/2008 EPA 524.2- Volatile Organics by GUMS ITEM RESULT UNITS RL MCL Method# Analyst Tested Note Carbon tetrachloride ND ug/L 0.50 5.0 EPA 524.2 yn 5/7/2008 Chlorobenzene ND ug/L 0.50 100 EPA 524.2 yn 5/7/2008 Chloroethane ND ug/L 0.50 EPA 524.2 yn 5/7/2008 Chloroform ND ug/L 0.50 8o EPA 524.2 y1i 5/7/2008 cis-1,2-Dichloroethene ND ug/L 0.50 70 EPA 524.2 yn 5/7/2008 cis-1,3-Dichloropropene ND ug/L 0.50 EPA 524.2 yn 5/7/2008 Dibromochlorotrethane ND ug/L 0.50 EPA 524.2 yn 5/7/2008 Dibromomethane ND ug/L 0.50 EPA 524.2 yn 5/7/2008 Ethylbenzene ND ug/L 0.50 700 EPA 524.2 yn 5/712008 Hexachlorobutadiene ND ug/L 0.50 EPA 524.2 yn 5/7/2008 Isopropylbenzene ND ug/L 0.50 EPA 524.2 yn 5/7/2008 Methylene chloride ND ug/L 0.50 5.0 EPA 524.2 yn 5/7/2008 Methyl-ter -butyl ether ND ug/L 0.50 EPA 524.2 yn 5/7/2008 Naphthalene ND ug/L 0.50 EPA 524.2 yn 5/7/2008 n-Butylbenzene ND ug/L 0.50 EPA 524.2 yn 5/7/2008 n-Propylbenzene ND ug/L 0.50 EPA 524.2 yn 5/7/2008 p-Isop ropy Ito luene ND ug/L 0.50 EPA 524.2 yn 5/7/2008 sec-Butylbenzene ND ug/L 0.50 EPA 524.2 yn 5/7/2008 Styrene ND ug/L 0.50 100 EPA 524.2 yn 5/7/2008 ter-Butylbenzene ND ug/L 0.50 EPA 524.2 yn 5/7/2008 Tetrachloroethene ND ug/L 0.50 5.0 EPA 524.2. yn 5/7/2008 Toluene ND ug/L 0.50 1000 EPA 524.2 yn 5/7/2008 Total xylenes ND ug/L 0.50 10000 EPA 524.2 yn 5/7/2008 trans-1,2-Dichloroethene ND ug/L 0.50 100 EPA 524.2 yn 5/7/2008 trans-1,3-Dichloropropene ND ug/L 0.50 EPA 524.2 yn 5/7/2008 Trichloroethene ND ug/L 0.50 5.0 EPA 524.2 yn 5/7/2008 Trichlorofluoromethane ND ug/L 0.50 EPA 524.2 yn 5/7/2008 Water sample meets the recommended limits for drinking water of all the above tested parameters. Approved By: La (Lab ctor)i ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605 q_5 No.-o�0 to— b Fee--------------------- ------------------ BOARD OF HEALTH TOWN OF BARNSTABLE Appiicat ion,for Ve[[ Construction Permit k�P lrv&,r �f Ap lic n is hereb ade for a permit to Construct ( ), Alter ( ), or Repair ( )an individual Well at: AOL— ocation — Address Assessors Map and Parcel ri-I&YL _ ner Ad ress— — _ —— —----— —— ----—--------- — — — — Installer Driller Address Type of Building �q Dwelling � - 1J - ----------------------------- Other - Type of Building---------------------------------- No. of Persons-------------------------- Lt fi Typeof Well -------------— —--- Capacity--------------------— --=—- — --—------ ----------- Purpose of Well----D-V - — ---- - ----- Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation until a Certificate .of Compliance has been issued by the Board of Health. Signed11 --— -- — -= -� - - date Application Approved By =--------------- -- --- ------------ date Application Disapproved for the follo ng reasons:---------------------------------------- -------------------------------------- ----------------------------------------------------------------------------------------- �( 2 date Permit No. _ .d l c7 C`1 --------------- Issued----—1 J - - — — date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of Compliance THIS IS TO CERTIFY, That the Individual Well Constructed ( ), tered ( ), or Repaired ( ) 'Installer at_______- ___ --�- - - - - -- - - - - --------- has been installed in accord with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. l`�2t71a-66----Dated-- d—��---- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE-------------------— - ----------—---------------- — -- Inspector------------------------------------------------------------------------ ---------------------- --------------------- ------- Q q-s No.----------- - � .� - Fee--------------------- ! BOARD OF HEALTH TOWN OF BARNSTABLE ZpplicationArMelt Con5tructionPermit E P11\0-r 01'r A� ' Ap lic tion is herebymade for a permit to Construct ( ), Alter ( ), or Repair ( )an individual Well at: �. - Location — Address Assessors Map and Parcel _ i ______ __�___J c `ter:__________----------_______ �__/_?� D� � -____ N caner Address Installer — Driller Address Type of Building Dwelling Other - Type of Building ---------- No. of Persons-----------------------__—_—________ 44 1 Type,of Well— --- ------ - ---—---- Capacity----:-------------— ---- - - --— Purpose of Well---- �?�' ------------------------—---- Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation until a Certificate .of Compliance has been issued by the Board of Health. Signed — - - ---- — - - -/ date t _'2jv— r(� Application Approved By— �^'`� !/-_------------- _ ` date Application Disapproved for the folio ing reasons:-----—---------------------—-------------------------------------------- 01 U 00 Issued----!_-`__� - — date Permit No. ----'— ------------— -- - date BOARD OF HEALTH TOWN OF BARNSTABLE ' Certificate Of Compliance THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired ( ) r by----- �- - -- - -—------------------ - - -- Installer at-------- - `—; ------------------------------------------------------------------- has been installed in accordar�'ce with the provisions of the Town of Barnstable Board of Healt Private Well Protection 0,9010 -ao Regulation as described in the application for Well Construction Permit No. ------------------------Dated----------------------- I THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE------------------—- — -- —------------ — -- Inspector------------------------------------------= - - ------------ ------------------------------------------------------------------------------------------------------ BOARD OF HEALTH j TOWN OF BARNSTABLE Vrll Cootruct ion Permit Ll No. --------------- Fee--------------- Permission is hereby granted-=-------- to Construct R(Q//), Alter ( ), or air ( ,an individual ell at:j No. — — a` -------- ��J/� —_ —-------- --- — — Street as shown on the application for a Well Construction Permit r _r v No. - � �� - —o--V------------ l '_ o Dated v .:, —r`` ----------- ------------------------------ — - -- — - j, Board of Health DATE---T -- i TOWN OF BARNSTABLE " ^ OCATION1/ SEWAGE # VILLAGE ASSESSOR'S MAP & LOT INSTALLERS NAME & PHONE NO... SEPTIC TANK CAPACITY If L- LEACHING FACILITY:(type) a;. (size) j NO. OF BEDROOMS => PRIVATE WELL OR PUBLIC WATER I BUILDER OR OWNER �� DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED.- VARIANCE GRANTED: Yes No i Q b? r Z� VI v t n� PC gc,CA � a o TOWN OF BARNSTABLEc,�� LOCATION '� �' a�ta-P�, ;y T SEWAGE # y/- : 33oA VILLAGE �{�. �t. ASSESSOR'S MAP & LOT ��Z' Z INSTALLER'S NAME & PHONE NO. A SEPTIC TANK CAPACITY O 0 LEACHING FACILITY:(type) (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER 5 .�.� ILL_ / �► �� DATE PERMIT ISSUED: s' Y -s C/ DATE COZIPLIANCE ISSUED: VARIANCE GRANTED: Yes No G� �1`6 Neu /a /go/v �Asl 61V Y74c, 4 z I 67f ' T� _ No... .z:j;�._1.o ��`� G<,tsL _VZ&............ V` THE OMMO EALfHOF JASSACHUSETTS EOA ® OF HEALTH ..........................................OF................................. Allpfiration for lliipuual Murky Tontitrurtiun ramit Application is h reby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at L ca•o Addres L.�� or t No. _ ....----•� .... ........... Own r i ` 4`Addr s a - --------------------------- - --`- �' s ...._.. _ .--- ..p ...... 'o . Installer A dre s Q ype of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms.......... ..............................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers — Cafeteria Q' Other fixtures ................................. . W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter__-____-____-._. Depth................ 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 ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water................... 14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ----------•-•----------•--•-•---•----•--------------------••-••.....------------.........._••.----••......................................................... 0 Description of Soil........................................................................................................................................................................ x V -•-------------------------------------•••---------------------------------------------•-•-•-•----------------------------------------------------•------------------------------•--.......------.------ W UNature of Repairs or Alterations—Answer when applicable.____..............................::�:........................................................ --------------•-••--------•---------------------------------------•--•-----------.-----......-----------------------------------------------------------------------•••------....----• Agreement: The undersigned agrees to install the aforedescribed Individual S wage Disposal S tem in accordance with the provisions of TITI.,I� 5 of the State Sanitary Code— The un sig e furthe ,ees n t to place the system i operation until a Certificate of Compliance has bee ed the b d f ealth. N Signed--------- -- - --....... --'-- -----------••--•--- - - ' ate Application Approved By------ • •--•-•------ -" ............ ..... ...... Date Application Disapproved for the following reasons-------------------------------------------------------------------------------------------------------------•-- .............................•--------•-----•------•-------------.....-----------•-•----•-----------.-•-- ------------------ Date PermitNo........ `�.`....Z= ............... Issued....................................................... Date IN o...........::�-30 �� of S='+��,�^''' "� �cc t�L F�$...:: ....... . THEOMMO EALPHC�' MASSACHUSETTS 1 � BOA ® OF HEALTH ....................... . ..............O F.........................................._._....................._.._................._.. Appliration for Disposal Works Tons ratrtion Prratif Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: - ..... �'........ `,...... i . ..................' -•-------------------•--• •-----•--• - ---••----•--------------.-----.----------- ... j j ac4o -Addre ' or Lot No. .�...... �....... .................................... ..._... ...... ._... \ Ow er (� } Addr ss i. p......_ t'.�_.... .. F.. I Installer Addre s d 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 Q' Other fixtures ---------------------------------- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter..._................ Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ (z, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a .........................................-..................................•---....---......-----......-----•-------•-------••--•---••----------------...... 0 Description of Soil..................................-..................................................................................................................................... x c.� ----------- •------------------ -------- --------- ---------------- ------------------------------- •----------------------------------------------------------------------------••--------------------------- W ----••••••-••---------------•...•-••--••---•--•--•-••-••••-•--------------------------....•--••--•-•---••------••-•--•-------------••-••-------•--••---•--•-------•-----•--•--•-------•-•--------------- UNature of Repairs or Alterations—Answer when applicable............................................................................................... ---------------------------------------•-----........--•-•---•---•-----------------.................---------------------------------------------------•--............................................. Agreement The undersigned agrees to install the aforedescribed Individual Sewage Disposal Sy tem in accordance with the provisions of TITS1 5 of the State Sanitary Code The unc[` sigile furthe ree t to place the system i operation until a Certificate of Compliance has been i� fie the \ rd bf j iealth Signed s r<. 1 :1. . -- ` '` ' n � j Date Application Approved By...... [ "' . ...................................c ^ I....... 5'_......C.`>/ ------•----•-•----------- `_ Date G Application Disapproved for the following reasons:-----•------•--------------•-------------------------------------------------------------------•-----•----.---•- ..........................••-•-----..-..........................._....--•---.....................................................•--- --•--......._. Date PermitNo........ ........ .. ................ Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH G�� (..............OF..... J.."r/!.................................................................... Tertifiratr of Tontplianre THIS IS TO CERTGIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired) bS ........._.....-Y %+y Ins alley at - 1 ri• t �! has been installed in accordance with the provisions of T ll--- ' , 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No-____..-•�y-___�-_Z)d_. da.ted..........------------------------------•_------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS 9 BOARD OF HEALTJH �[ �� .............. �?t :�:�......OF..........1. �!..a.�. ( Y............................._........ No.. . .................. FEE IR57 ----- DiopooFal Works T-FaIno#rttr$ion rrntit Permission is hereby granted.......Zf........ -�--••••----•••-•••---------•-••-••-••••-•••-•••-••••-••-•.....--•••••--•.....•-•................ to Construct ) or Repair � an Individual Sewage D,i�posal System p,, Y� at No.....................Y.:l_--•--lY(_..... ... Street C as shown on the application for Disposal Works Construction Permit No =. __ Dated------------------------------------------ ................................------------------------•------- - --•-........................................................... Q C/ Board of Health DATE •l ---------------•--•............................ FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS FRic ............... THE COMMONWEALTH OF MAS'SACHUSETTS BOARD OF HEALTH ...........................................OF.............................................. Appliratiou for Bhipaaal 10orkii Tomitrurtion rumit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal S at: I.... ....... .............................. -- -----------*--------------*-----------------r...Lot---No."................................."------- Locatio ....... ...... ............ ............................................. ........................ ............................... ......... . ----------- A Qwaer 44dress System . 7.. .........Address.......... I'14,14,4A ........... . . ..... • - ...g ............. . . ...........le� .. . .... . .......................... ........ ........................ill. . .............. ........ Installer Ad"dir'e"s's' U Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder ( ) P4 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) A4Other fixtures ..................................................................................................................................................... W Design Flow............................................gallons per person per day. Total daily flow.............................................gallons. 1:4 Septic Tank—Liquid*capacity/eW.-gallons Length................ Width................ Diameter-..------------- Depth................ Disposal Trench—No..................... Width.................... Total Length...--................Total leaching area--------------------sq. f t. Seepage Pit No.....: ----------- Diameter... ... Depth below inlet.................... Total leaching area.....*...........sq. f t. Z Other Distribution box 04) Dosing tank ( )' Percolation Test Results Performed by.......................................................................... Date........................................ �4 Test Pit No. I................minutes per inch Depth of Test Pit................--.. Depth to ground water..----.-................ Test Pit No. 2................minutes per inch Depth of Test Pit.........._..--..... Depth to ground water........--.............. ---------------------------------------*---------------------**----------------"......."...*--------------"----------------*....*---*...*............... 0 Description of Soil........................................................................................................................................................................ W ..........:............................................................................................................................................................................................. U .....................................................I.................................................................................................................................................. U Nature of Repairs or Alterations—Answer when applicable................................................................................................ ........................................................................................................................................................................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board h. Signed.. ...r............. .......................................... ............................... Date ApplicationApproved By.................................................................................................. ........................................ I Date Application Disapproved for the following reasons:................................................................................................................ ......................................................................................................................................................................................................... Date PermitNo..................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSV3&(Z,, BOARD OF HEALTH .0 0 F.......... .................................... Trdifiratr of (A-lumpliana THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired by............ ........ 2.4 'ftd:;??Z7•..................................................................................................................... L:5 .... ....... ......,,�staller at .... ........... has been installed in accordance with the provisions of TITLE. 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No...<� ..�_ -.-9'5--L......... dated___...--._..................................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................................................................... No`. .../�C!S . Fps............................ ..--- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...............:.........................OF................-....-... ........... Appliratiun for Bigpuuttl Works Tongtruriion ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: SA l� ................__....5.._......................,......t...---------•-..............---••••._... .........---------------......................-••---Ro.......................................... Lsocation-Address r or Lot No. ............5..................•---••.............._..._•-•......._....-.......................... ..........--................................................................ Owner a vY .ddress... r�........................ ...::...............................instal ............................................... lj Installer ddress UType of Building 3 Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) a'_l Other—T e of Building No. of persons............................ Showers YP g ----•-•-•------------------- P ( ) — Cafeteria ( ) Otherfixtures .........................------------------------------------------------------------------------------------------------- ... -------------------- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid*capacityfj?e�..gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No...... ........... Diameter..f -- .._. Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box (X ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water.......-................ Lz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ •-- -•--•-•--------------------------------------------•-----•-----•---...._......•..........-•-•-------.............................................. ----•-•• O Description of Soil....................................................•----......_.....__.._..------•-•-----------•-----...-•----------•-----•--.......-•-------.......---•--•---•----•--- x U ---•--•••••--•--•••••••••••••--•••••-••--•-•-••-••--•-••••••••••--•-••••••---......••-----••••••-••-•--••.....•--••••••••-•••----•••••-••-•---••-•------•-•••..............•---•....-•••••............•- 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 the provisions of TITS...^ p 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 the board of health. Signed----......-•- -------••`=__••------•--•-------••---•---....-- u Da t e-••••-......-- Application Approved By.................................................................................................. ................... Date Application Disapproved for the following reasons--------------------------------------------------------------------------------•------------------------....... ---------------------•----------------------•------•-----•-----------------__.---------.---•------____-_------•--.--_--••------------------------------------------------------------------•------------ Date PermitNo....................................................... Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH /"- zw O F. ^ - r .......................................... Wlertifirtttr of Tumplianrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired bY................... '= ......................... <' -:.:.... = ...... ............Installer --� 77 ' -----------•---- ------------------------------ . • • ......•••-•-•---•-•--•••-•--......•••••-......-•••-•--.._........•----- has been installed in accordance with the provisions of TITLE j of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.__ !'---`---:--_ ...........______-___. dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF-HEALTH �/)............ rr..`...:: .............OF..--..-.:7:.7::........._.--........ FEE........................ Dispasal Workii Tunitr ion "truth Permission is,hereby granted...........r to Construct ( )ror Repair ( ) an Individual Sewage Disposal System --� at No. , f 1 street as shown on the application for Disposal Works Construction Permit No............... .... Dated.......................................... DATE. • -�� Board of Health o- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS