HomeMy WebLinkAbout0047 CLOVER LANE - Health 47 CLOVER LANE, MARST.MILLS
FEB-17-00 11 :21 PM SOMEBODY ELSE SEPTIC 15088961874
j
P. 02
I Ei.EIVE0
i F F R 1 7 2000
TOWN OF8AANSTAB
L i
. _ pLTN aF ►1tiASSACHUSETT HfAL1H0EpT.
-:. ..' COMMONS IMRONMENTAL AYFAIRS `P.,
t ExECUTNE OFFICE OF E
L NTAL nOTECTION r
4 ( DgppRTIALNT OF �OUME09 (6171292•5500
VTER STREET.BOSTO.'
4:.'. ONE W .
TRUDY CORE
DAIAD B STRUMS
Cotnrntsseoae+
;t I TSpN FORait
At SYS �IN
E: j : ARGEOPAU► C£ LL'•CCI' AGEOtSPOS
k Governor 'SUBSURFACE SEWAGE PART A
i CERWICAT10N
.s� ( "BMW of Owne+ On►
S ~f vier �• Address of o•Mr &,S trrl "A •OZ;Z7
Peoot►t1 Add`",`+ SiJar� iIS �C'
i
Ads 1
pate Of fns Z/I' DO s . >r"S�on 1S.310 01 Tide S t310 CUP
15.000
ffarlre of lns;Z. IPteati Ass insp�or P'Xs an,to
. 1 am a O P trppy�ed sys< •A Z6Jj 'Ot78
Mtileng Addr p sccwate
H Heal below is true.
�' Tde4lio^e
an that the intormaaon repo ro er function and
hi trs;ninp.snA eapeeience in the p p
11'f TtF1CATt N :ATEsA �spected the sewage disposal system at t s addresi a
F 1 (ceR;fV that h° f pets a of iaspeetion. The inspection was Ptrtormed OaitO 0^my
}} algid templet as The SYsicm:
n-site s wage disposal systems..
maintenonce'of �1
nsses Authority
" ( onFu Passes
the Local APPr ts ON�
Fvnhe+Evatuat:on By
_ Q�pU
Octe: --�'�
utttOrity l6osrd of►1eslth or OEPiwiehen th+.ty t301 days of
rtstir•the inspects and the system Ow""
S rOvrn A
j 1ntPeC1or s, a•t to the ADP g
of this mspecuon rep 1 1
0.00
0 gDd O1 g should be sent tom
all subntrf a copy ' ^AD wort rotscli TheOriginal
The Syseerl►fn peetor ll tfu system is a shseed sYstem or has ardree"'g floe mental P
tun tfti inspect on. ; nal office of the Depsn it
cOmpl .11 ate rc9 o and the sPPiO"`^g suttwt Y
.il.: t two report o the aPPtOp^ +csfNe.
•fI' el.i1.t�PPI
Her.and copies semi to et+e fwy
;. system
OMb -
_ � C.
: 1
ElITS
NOTES ANO COMM
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<ti 1
FEB-17-00 11 :21 PM SOMEBODY ELSE SEPTIC 15088961974 P.O3
-
.1
�� t I I SYSTEM�pEGSI(kiFOPJN
a•. I CESfVYAGE A
f; I Stf>lA PART
CVICATtpil(owd-"
'.I 1 clever11h.
;-,k
$ C,of a in 310 CUR 15.303 ssist. AaY�e
Sys,M P>S described
i A. f that any of t"t°�e corditiorrs
i intorma*on whch p►�1Oates
t have'�s are indcated below.
' I I ""r
PASSES: _ ed to be feptaced os repaired. The system.Wot+
1.
SrST i F woo IWI owcots as descr+ "Pass
'Ded in the' of Health.we Pus
fn co,
[F IUA 'm o1 �p>sOement a f ew'as appr°ved b'f +dot is ad instances. H' �a copy-f a��ol.of
basis oem insP�t i Lw-,6w,:
I �at'�e pas peoaded die syst poor to the data o1 d►e a t V&
owner,'OPef*W1 . (Y.ti.a NOt- yeamar�icate yes.Oro. not T is metah urJauth!rt twei+tyslw 's fiatiq t or8ttration or s .Pdc ma as
Fe( tat,is ricked.atrueurraglfnnsbn0 s is teNaced w i c�+PlYi^g
;E the a u. `.syst wa pass kapecfan rt>!re
E � !ed by tow tiovd of tlaaid►
#` Vjed 0i0S)
is j + ��pution box is due so broken of° d of
p high static water beset o e pass inspKt>on
it(..m app wo 01 the
sysSew backuP a b,"110to d a uneven disuamtion box.
The
�{. �y o s broken,s .
jMca® ="d••`�' broken PWst are replaced
!
obstnreeon box a teve><ed a replaced ��
due l st. Vw Tym-
i ! d'steRwbo^ to brotien ar t> ._
jo funs s~Y�
t' Tfu n teriubedwithP pP,.Vd off�of NerdthY
E � I
we reptec
=i t otlstn�+on is removed
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FEB-17-00 11 :22 PM SOMEBODY ELSE SEPTIC 15088961874 P. 04
' I z
POW SYSIM
}
wgSACE SEW
p�Avwd-+ed1
CERIW
G10%4r L4%.
4the 9 '
in order to OF{ZEAL- to protect
the
AL T10N REQ�8Y THE BOARD OFthe system'ts fa4
flcfrd of Health Aetermine
f� i _ xist wluth reWnf ttatr ew• On {5 3D3 l{1N1 THAT THE SYST8A
Cen6twn` the OW o--" vAn4 3{0 GEAR
.t-
c P.
sd j end METH DETO"W 5 V'A WXjejL AND SAMY AND
fl<Ol►fdD T THE P{1 �
f11 SYST PAS�G W A�YA}D1ER WHIM
is f101f Teoa4'■ mar
esspod� so
or pnW rs within feet of f porat �dd'^9t'K teet
at
wedend er or f setsfi.
+; sspaotlor priW wrtlan
I i Ty{AT THE SY5"s
VEMUNIES
peJg X WATO S V"JMAP gtyf{OIO
I pp HEpETN(AO SAFM
Xq ` A W►XCESSTHE " tTH the SAS is wrtt+�^{�feet of f sreface water supph of
r23 tear(AT SA
tam has a sepoc tank end sd' Of pa°r`sYs t of a public Mrfta svA[+h
c The s to a t�etaoe water sarpplY•Ica ��system end ft SAS.is�f Z�of a Pirate wft of t1 wsfl.
r theern has a seals t took mind sag ays«ption sYstam a SAS is less than tSAS isf�0 f� feet es d�
"f The sYstern has a>� and soi absaVLO"sys� for err battens a"O ei regen is ewd to or less
gri"g
i
weter so*0noni
The �d'et U, ty and ddw'41presen 0 wag water a cevstem (mwe'a"aboo
r
}r: I;. weA1ls fete frow►p�A10au of Adenr°°e distance.r---
Niethod
I S Wn-
J .
F I al oTH
C: 1
°tE
E
€ �
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FEB-17-00 11 :23 PM SOMEBODY ELSE SEPTIC 15088961874 P.05
I I.
1
iI
88SVECTIM F0w
k SWAGE OiSpOSAL SYSTM
SUBSl1RFACE p�A
T�,AT101t loosrlMa�
rocAMIN il
/f/ The basis fa dys
Does. wd e� leiw•
F .I. owing: as described in 310 CUR 15.303-�to cow the e.
3, fell
=r�' D_ ;SYSTBA y I s or'plo" to each-of wing tune tardtions etitt detdmate w1►at be rtecess
3 re of the toito betacted to
> .. Y atl e►av de en^ined4 ern The Boa►d of Heald►sf►a>1d use
date V - dseao an ovalo�d eel SAS at
: + Copp
�' 1 Yes No geCkoD d � � ovnd or surface waters due to an overdoaded do99
M ( or po ittp of etf(uent to the surface at ells¢
;, pis te SAS or Cessp�-
eess?aII�' in"n due to an overloaded a do99cd
ottilet
�F4+id level ill '%'Uibuoo-bOx above
w �at avaiat+k volume is Less than 1 f2 day SOS`.
Is less dtaa 6� °
rLi4UJ depth in cesspool tlwn+timers in.the last year NOT due to dogged°'ebstrutted pdKlsL
of saes Prs^D� a bolo ounRttqw�td Pumping motdvrater de+aba`-
�,,,,t w the tng►�¢
' i �- System.
Cesspool
°r�� to suvis-e watat supply-
Any'D�on of the Soa Absorption eee water supply or"ibut"
within lop teat of a surf
Ar►Y portion of a cesspool of pmy Well.
•Zone l of a p
4 a Cesspod a prMt ie-+wiS"" well.
� � of a cesspod err patW K trRlrn feet of a prorate wrier supply
het from a p„.water supply W ll �
;E t portion er tt+an Copy of wail _
w Pt^�y is less than 100as� el be acceptable
s
I I Am IV Pw�Awe water quaky�afysts. M�wd atvoar'i's tetragon ettd eft WWI wtrate nitrFred to
ogen .
,f� wtn beetetta.volstde o►9° cort
t` E of the fosowim"
FA Q or•H to to systart�s addition to the eritena above. �'and tfte system is a swuficant tlraat u t
You ��ne.ia apply eater(Large Syst
a¢ exist-
Yates s a tacwty r dew Sow of 10.00 y conytians
' e Of ow
s serve nt becauseesub one
s- 1` _„A safety and the em"T
va. j WOW supply
�---
aYes die hem is win 400 feet of a suAace drirdun9
�.. s . ter+wPfuY :. Zone t!of a Pt
'4i' I the syatata iawitlw►200 feet o�u WeStre�protection Ales
ryYPAI er•mapped�F. II was l�erim
s dw is located in•nitrogen sensitive
e I:. ppiy Weill n eCcordance with 310 CTAR 15-304(21. Please consult the load re�ara
such system shall upgrade the sVste+n t
star
of any
Theo a or ant for informationotfit6e o Jihe Oe1ja '
iv i I
s i
-11 f i
FED-17-00 11 :24 PM SOMEBODY ELSE SEPTIC 15088961874 P.06
FORM
... k St1f1Si ACE SEWAGE Off` SYSTf�1
pARYB
ABA=� 4 c�ot1'c-r Ln• .
..frrapartlt rq.Aerty
bmsplm
en done*You Must j,&Cste either'Yes"Or
-plo as to each of the foRo'rimg=
t �it the fogo�in have b4
j _
t � ant,of 16osrd of Heshh- �l�w
Yes f10 rftfoffnsiurn was provided by the°wnef, paa�sp art of this
✓ mpn9 �a dOF� t weed into the systarn recer►dy a ss t
6i'�'�s � volufnes of water here not been
I%onai IC r teaingtperiod.
`ttrt I( I d with MIA.
t %spe�Or Hotc if they are nat
avaHabte w
`. d and ea .
men Obtained
s built ons have backuP
i sewage t
k !� rre6ing was inspected for sites o
The foci Ityowd
waste Now-
i
The s antreceive"oh'��w
s not receive
The sk was insp�e srg`s of breakout• been located or+the site. .
AbswD system
•escludin9 the Sal ' is was
inspected for eo+>�n of baffles
k Ay sys em componentserror of the sap
fic and Aye M� depth of scu-
;�. � ., umd'wswere uncovered. be
opened.of 6Wd•mod'of sludge.
se
The s taatk o1 s(rtlebon. ". stern onthe'sht has been diet
as tee! .material Sal AbswW°n SY
i The a and location
of the gdormaeon For example•plan at B.O.H. at issue,gW.51wwion of distance is Copt ble)
C is
J Of any
of the failure criteria related to Parti.: Oct in the field �ppesf
(15.:02131tb11 fr i ��raydad
t� / H dctluml m+
.: ✓� The owotx fartd
�- aea Disposal Systen+s.
i
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1
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FEB-17-00 11 :24 PM SOMEBODY ELSE SEPTIC 15098961874 P. 07
FOR
" SUSsAWACE SrWAGE 0 SVSTM � �
cr' is PART CsysTva TtOM
d"
r: A F/?hC Y
Daft
,L 5
:lactuan 3
fbw O p.d. Numbe+of bedre ►
go. r of bedr
-` ii, � Tamf:�fSiGN�aw vn ter ,rn .
T R lsepar ( or noVillp no1:�' . If yes•seW wgins" ion:n�n►ad
c.~ to y len+l (yes Of
Sao""as*t �Oy able lit two yem s usa0a(9P�
Ws1�meter H
pun* nol:
. :�: t.asf data of
?:.
Type of (Based on 15.t031
pdign*NW:
awls of `p
.. , siet+ss trap. I1Ra ud serer fires or no)----
pre
�f"w ° to the Tide 5 system:ItleS of^°1—
- yA�atet ttteteo'
. Last date of
r;: I
l t 07"m 1 �ORMATM
Goorf' Lam o11 y —
saw,*of informs"":
ovs
Of insVecd°n (yes ee nol�°S
C yet PROM
s tog
{ TwK OF tt 1 eo:lsoa eb:«olio^sysfen'
ce
cc Pol
;nspecoon records.0
ev s ar►v1 act
I� se syst Ives«not Crf yes.ettsco waste oparstoa and makde-ac eonu
VA Te etc.Attach copy of uP
} r"r T Tank C.0 of O£P APW-*a
60,
Other draf°ea'se°n'
p o!sd eomPo^ents.date insta9ad fit knownl source
` • A," l!
del ed wh."emmn9 st the sAe.(yes a nol
odwsr
tE iI
FEB-17-00 11 :25 PM SOMEBODY ELSE SEPTIC 1508896:1874 P.O8
SURFACE SEWAGEUSPOSAL
>415 fSUB .
i P MMUM 111101(omd"°4
lC/ov Lit.
epth: COet� St Tfef1�„• �. f��=�C1i1�
COD f
2� i wale[ well ri suttiwh
Distottce 6om I/'vet
�i.. at
• • VMtj119•ewe
q. -
S
pecete ott site
�otlhu( htpletn{
JL of etad i+bri�hhs PdYetfehhe e
twn�+ a °{
eottfinwd by a o1 Gonhp
CettiScaS
a tee is
SMid9e of Dude[tee
� of battle-
to bottwth
l b e t tea oe belfk: u
Sty � � to top o/outle
�ta/IGO °t cum to tpt,am of Outlet tee
D�hee a rS dro
' HOW !re s•dsptlt et 4'+ t h►�in tole to outlet' .
d I struetwd inte9M1►•
of end Outlet tees or
i II fet
fit} .l �
� i
s -d F&040" Pohf�hlae°e—
<f
Oe�� eonerete met
! Snah+ to top of outlet tee a btlAe:_.—
F: i �jsteme uw of om of q/det tee ar baMr.�_
bonorn scum to butt
�� ► �t�e
ioveM st►ucturoi integ�ty
°k _ ,ee+h out/et
tees m
dn�on ei inlet end b0fles•depth of it�ad level in tdetton to outlet
for y
p (t a .{
- r`. evide at 9a
4}}}
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FEB-17-00 11 :26 PM SOMEBODY ELSE SEPTIC 15088961874 P. 09
F
- i
- I
Jr FORIA
' ' ' GE pfSPOSAI SrStEH uP-...,.r..�VfV
SUBSURFACE SEWAGE �'•
4 .. PARTG
I.
e 1 C( VCr"Ln•
i }of,inspn
.r T T rank most be W-4-4 prior to.a at tie+.e e
r > ocab on I
�,. •� Pdyed+'ArM�°d'erlesPtainl
`€ VJ*bdOw wr.aete_et+f_..Fr glass _-•-
. coon•
IAdaid of c
:f
Ions
sow; q t{ons/day
€ Alom Pre in worldnS order.Yes l
Aorm f.-
c s .
Qste of Pre i
1 Com!nd'ts=i_ of span end q°°tct+es,etc.)
+� t tee,t
. y
}
' p°ca1c enisfa
f loYd
a }
��et ; deuce of leskW fide out of 6oY.Ott.
ewiderKs et scS&carry°ver'
6 is egwd•
it Iowa
k. ..
PUS
PL4
aetaf
. ,
pal,
:(res er
i. Armes in
ire:a Sol'-
1. m osk�rW eaAlwwds
rxi 'of 9 WW-ppw%
fieandof
?� 1
ss
r. t
FEB-17-00 11 :26 PM SOMEBODY ELSE SEPTIC 15089961874 P. 10
I
- i
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3 '.
=I
SYSTEM tNSPECnm FORM
tc' SEWAGE DISPOSAL
�q¢ StlgStAlfACf PART C
i SYSTEM wffORMATIOI1( dl
�. � Add�t� �1�. LA•
I> Cb t
by
4 . be sPO�
ezcs�not rewired•�bo^m•Y
I :AocMt an elto a) °°s
nat located.6 n.
Two. UNDO
moramn—
{;
monbes.rd
►�-----
y�.�,.. ow Bess .
M i T• ,olopy: �,etc.►
.. I+,
of
damp soa.con*('
at sa8. of h auk fdu.e:Mwe1 of 0�"� a
;6}: pecto
me
} 10*0
pi of
of ash
P:.t "stowls
wed as lotats0 oe)i � .�be w
ter/soi:s;yns of hYdra%6c faiuro.M�►et of�9• °of wregstatio^•am.)
tootu e
„ i . (locate plea) Ou^•^s�°ns:_"'r`
1
eriel of onstru
1 . INW
0010 e s s" moo^of v taeion,etc.)
no cow s: u6c 1m7we•feral of pa'�' 9
of s .signs of hydra
(note c
;( is
FEB-17-00411 :27 PM SOMEBODY ELSE SEPTIC 15088961874 P. 11
F. I
! now FORM
1 SURFACE SEWAt:E OSPOSAL
swum
PART C
{{ S tsTm WWOWATv"
Gl ver to
o.� IF :Ae�ty f
DOW
OF S1L 51f5 eat tefete, 1s�►d"1°tk� con-AS
twuscl
`= to et cast two
loco*anweds 100'(Locate wherc public
: ,
-ff`
q. j /� ( 3Z Q l
,.
t. I .44-- ems,
84
t
�F 1 ooze
!cam' A- To
oll wp Its
F�
I
iii} t
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FEB-17-00 11 :27 PM SOMEBODY ELSE SEPTIC 15088961874 P. 12
iFOMA
�
4 DACE SEWAGE V6 �t-UM V4SPEG"
i
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i T1011 60014-11,43
r I I SYSTEM 0
O.ia.!e Fl tY
�d /l/Qo
_ i 1
So° de th to W water
oat. a alit
USGS Ok Waft clocked Moderate - ---gyp
to depd�: S}bpowl
. SITE EXAM swfaceJ�-F-mlo �0
. : i Shaftowl wafts
-led aeP�"t G► waleu, f2Feet t
h Ground+vster Be�+�^'
"� on the►*� used. dstartiine Fr9
Please T -
ypesi plans on►eco►d
��y.oDs�vata►►hole.besemeot stanp etc" -
Obseew0
feu►
a` i Oita 6oen eort6t+oas
j. madPith be goard o1 heats►
irecords
I moving
a vat ors.inste0ers
L. US 2S pate.
9r�
per M,ps Elcv SZ
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1
TOWN OF BARNSTABLE
�y l
LOCATION - SEWAGE
VILLAGE k0JV ti O A ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO. _AYOtlE J
SEPTIC TANK CAPACITY 1000
"L LEACHING FACILITY:(type) (size) �t,S/
NO. OF BEDROOMS PRIVATE WELL R PUBLIC WATER
BUILDER OR OWNER j�J y
DATE PERMIT ISSUED:
DATE . COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
a
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH tem- c�Qdfa
g
.............. r . ... oF......-.." R 3 ,. ......................
APpliration for Bhipasal Worko T anstrur#iun Ilrrmit
Application is hereby made for a Permit to Construct 06, or Repair ( ) an Individual Sewage Disposal
System at
. �(� --Locai� Address _..._.._.... ... or Lot No
1� �.1 �� . yL ............................... . ........
�6
Installer Address
Type of Building 3 Size Lot....
4�- r.�S...Sq. feet
�.. Dwelling—No. of Bedrooms..................................:.........Expansion Attic ( ) Garbage Grinder ( )
Other—Type e of Building No. of persons............................ Showers
f� YP g .........:.................. p Cafeteria ( )
p' Other fixtures
Design Flow..............110...... ._..gallons per person per day. Total daily flow.........:.�M.C:�...............gallons.
Septic Tank—Liquid V.gallons Length._O�Ge". Width:....,..1tv.. Diameter..... ... Depth..1Z
Disposal Trench—No.................... Width................... Total Length Total leaching area....................sq. ft.
3 Seepage Pit No..j!: �(5.- Diameter.......IC?...... Depth below inlet............... Total leaching area.��. sq. ft.,
Z Other Distribution box (X) Dosing tank ( )
ti Percolation Test Results Performed by........��-.....�...� � 4--.......... (r�.....
...- -----.�...-'s�...•.�• Date.:............
Test Pit No. 1.........Z.mmutes per inch Depth of Test Pit......1 Z ..... Depth to ground water.. .4.!`l. ..
fT4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
04 ................................... .... ... ...••••--...............................................................................--_.....
O Description of Soil.....1:q.--...V-2 .....4.tfl...-5 .!4-- ......... .............. .........
"►4 ICE 51 /
:................ ... ..........
..........
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 LITL: 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of C pliance 'ssued by the Ward o Iea
(�� Signed.. ....... .............. ••. . . _...... .. ........ ... ...... ......L.--�:� ,
� .
Date
Application Approved By......- --- z:......�.G.................. -••---•-•-•----•---•--- .� -.-..........
Date
Application Disapproved for the following reasons:...........................•--....------.......---•--...... ......---.......-•---........................._..
r
. Date
PermitNo........ ......... . _...... �''"� Issued................ .........._.....................
Date
7
� r !
No......................._ FEB............»...........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH te -t �.Spi�.CrG�
..........:....OF........ l�Rl t"; � . . ..........._.. f i,4
Applirkion for Disposal Works Tonstrur#ion Ilrrmi#
Application is hereby made for a Permit to Construct (x) or Repair ( ) an Individual Sewage Disposal
System at:
....
Loca il-Address t � r Lot...
4 _ Owners r G .. ....... Address .....!..............�..t...r.......«........
a ..... Installer 1 V 11r r r4i 0# Address ......................................
Type of Building 3 Size Lot.... 3 &...Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder
Other—Type ( )
G4of Buildin g ••.....................•--•- No. of Persons............................ Showers ( ) — Cafeteria ( )
a' Other fixtures
Design Flow..............� t C�......._...........gallons per person per day. Total daily flow.......... .. r>. . . gal
W ' I� t �� . .......... lops.
WSeptic Tank—Liquid capacity gallons Length-__�.a...n". Width:l-..'._l �... Diameter..._.- Depth:'!'5. ' -...
x Disposal Trench—No..................... Width.................... Total Length....................Total leaching area....................sq. ft.
3 Seepage Pit Diameter....... Depth below inlet......G.......... Total leaching area. -••�2..sq. ft.
Z Other Distribution box (X) Dosing tank ( )
Percolation Test Results Performed by......... ��E`«' ... Date.......4 2-g'."r � ._...
Test Pit No. 1....G ._.minutes per inch Depth of Test Pit......i-2::'...._. Depth to ground water..^-10 N-4�=_r
f� Test Pit No. 2...............:minutes per inch Depth of Test Pit.................... Depth to ground water........................
O Description of Soil.._.�......................................................I ' 1 :. •iLs... - ...... ..... ...........................
=. .............. ...........................
fCa 5' 1 lam'-r i�� r .... .. ��..+ . .�l L.,
------------------•---------- ---------------.------........-••---_ .........
UW ---------------•-••------------........--•---••....--•--�t�l�..r.... .. .<I ...:........--•-•------,..-•--•----_.........................................
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 TITL: 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has—be-en issued by the board of-health:
nA
� -L-- Signed.......k............................................. � ........... ��e-1,<..,.,.C.�.-
......
Date
Application Approved By...............�.......... :.......
Date
Application Disapproved for the following reasons:.............................•..............._..................._......._..................................««
.........................................................•-••----.........---....--•---.......-•---• •.............-------------.-------•.........-...... ................................«
Date
PermitNo......... �-------.. _...... Issued.......................................................
D�
THE COMMONWEALTH OF MASSACHUSETTS
r" S
BOARD OF HEALTH
VAt In if irtt#r of leuut�rli�tnrr
THIS-S TO CERTIFY, That the-Individual Sewage Disposal System constructed ( ) or Repaired ( )
by............. .... "'"'c ''1; . C I`J' ►Y14�... . ... X................................
Installer
at......................... �t1 ` - C�V T+/Z �.nr� , r t
.............. ..........--•---••----....... .........--... .......... ....... ......._... ...............................
has beeri�(installed in accordance with the provisions of TITLE. 5 of The State Sanitary Code las described in the
application for Dhsposal Works Construction Permit No....��� _.... .�b....... dated....... 12 ..............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE............................................................................... Inspector....................... _...... .....................................
M THE COMMONWEALTH OF MASSACHUSETTS.-U. ;
114
BOARD'.OFrHLT���".:-.. .�...f........
OF..... r�`" ��-_., .cam-_
f....... ... ...... -� �r Fu.......... .............
Disposal- arks TunstrW--iu�n f rrmit
Permission is hereby granted > .. ..�. l^`a:"y .. !9 ...
.....-
to Construct ( L)or Repair ( ) an Individual Sewage, Disposal System
atNo......................... .. '. ...' ::...................._............... :..... ......
Street JJ
as shown on the•application for Disposal Works Construction Permit No ...7 —ate
-.•..-« Board of health
DATE. ...... .......................................................
Department of Environmental Management/1311II(ision of Water Resources
WATER WELL COMPLETION REPORT
WELL LOCATIONAddress /_+.� 'li- �,/�„ sir Lam.+ LC
v
City/Town A�,l� r 11 f r � /W',
G.S.Quadrangle Map �S
Grid Location
Owner w(ri/IY C l+ f
Address S16-1q—.. 4r99 &AAn,nn,no7`" AAM A 7 9�
WELL USE CONSOLIDATED WELL
Domestic❑"Public ❑ Industrial ❑
Type of Water-bearing Rock
Other Water-bearing Zones
Method Drilled l f a�s,P/
1) From To
r 2) From To
Date Drilled 31 From To
7 h
4) From—To-
CASING11 r( Depth to Bedrock
Length �/ Diameter 'tip
Type lue UNCONSOLIDATED WELL
STATIC WATER LEVEL Water-bearing Materials
Feet below land surface 47f / Sand: fine❑. medium❑ coarse Q"
Date measured - /a%[ Gravel: fine❑ medium❑ coarse[]
GRAVEL PACK WELL Screen:
r-� Slot#length V from 4 to /_a
U
Yes No ❑
Split Screen (or 2nd screen)
WATER QUALITY TESTS MADE Slot# length from to
Chemical ❑ Biolcgical�❑— Depth To Bedrock
PUMP TEST
i
Drawdown feet after pumping . days hours at A/, GPM.
How measured Recovery feet after hours.
LOG of FORMATIONS COMMENTS: (On well or water)
Materials From To
0
Cb
n
DRILLER
cb
�t o
Address ar^
City n D 0
Registration No. -0 C^
JIi}iIi"-/f !
" operator's Signature
ease print tirmly BOARD OF HEALTH COPY 25M 10•85•807101
SECTION - SEWAGE µ'
CB 3 E loi.90WH' " F
SEPTIC TANK — r _ „D.'BOX _ I —LEACH PI T \
TOP D/N���
.IC
!Q IMSL)r �feTO i" _
r �\ WASHED STONE + Y
• J I ICI !� ( cov
Imo' 3
' IN. y ,
OUT. IN• 1 )r,,� LIP,
I� \
_� 1 •( l�G I OUT• IN-
TANK
.i. I •F•� `rl ) ,.
SEPTIC
�► X .
ELEV. TANK
I \ �.
ELEV. ELEV. _Ix1_c ELEV.
I
' ELEV. ELEV.
f5►
--�! OF�4"-14ta
WASHED STONE
S
TEST HOLE LOG p- sqe•,Z
TEST BY 9AAIifd.IK �- 8/'CJ / .(ley J
WITNESS \ / ��- �vv \ " �l � •
TEST DATE 41�_ DESIGN —BEDROOM HOUSE v
T.H. 2 T.H.
a[ ELEV.CN }I ELEV. NO SMItH l9 ` f 1�IEL � :
IjB Il.. 1 PERQ RATE .MINAN. DISPOSER ISPOSER
Ig �S•3 FLOW RATE IO (GAL./DAY)
LA kSft OF SEPTIC TANK ' S _
REO'D SEPTIC TANK SIZE
D LEACH FACILITY
���
►�{ Ll SIDE WALLo 'f� pi : (2�1 - 1 G/D.
BOTTOM ( Z — ( 1,0 ): — G/D.
n r TOTAL ¢9
144
- o
USE: � _L� LEACHING
IV� WATER ENCOUNTERED � �'�t\�I��� } /
NOTES: (UNLESS OTHERWISE{NOTED)
�]
1. DATUM(MSL)+TAKEN FR0M f !42._ �vl_I-__-QUADRANGLE MAP
2.MUNICIPAL WATER _�� .-
3.PIPE PITCH:Va"PER FOOT
4.DESIGN LOADING FOR ALL PRE-CAST UNITS:AASHO- qq
5.MIN.GROUND COVER OVER ALL SEWAGE FACILITIES: (1) FT. Si
6.PIPE JOINTS SHALL BE MADE WATER TIGHT
7.CONSTRUCTION DETAILS TO BE ACCORDANCE WITH COMM.OF MASS. },
STATE ENVIRONMENTAL CODE TITLES CIVIL i� I f
3.,fHl5 PL1�t.1 �PRJ wlp� 0I,A-Y A►,v G-40u_p E ' �E :tc;'��; + � � h SITE PLAN
nJ ,-
KlGrr � U�D FOR C->! �Y > L'F ✓ LOCUS:�i�J4r
RNE
yPg+QFi♦i5SI NAL E INEER H. s �(�D^(I �O�J A�ti �' � r--
I I
OJA EF: :: tS-ti
down cope eagineeting ,��. M 1J i':n PREPARED FOR: ha�Leo
CIVIL ENGINEERS
BOARD OF HEALTH I'l LAND SURVEYORS
REG.I:At��YOR i
CONTOURS (EXISTING)--------- r, 020 Main St. 1 — I c
(PROPOSED)-O-0-0-4- APPROVED DATE h'l/,�z(��Il��✓I� MA �, �q SCALE-1 -�Q( DATE