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HomeMy WebLinkAbout0007 HIGHPOINT ROAD - Health 7 Highpoint Road Marstons Mills. P — —- --- -- - - - - - --- A = 028 041 �\ I l I i i I THE Town of Barnstable Department of Regulatory Services Public Health Division Bate -4aO a tl� MA9,Y � t639 200 Main Street,Hyannis MA 02601 Oo1 i b Date Scheduled hV Aw//d'J''� Ttme . Fee Pd. ,I I� on Sol Suitability Assessmentfor Se Disp s Q Performed By::_._lLL�'y��Jt'1 Witnessed By: LOCATION& GE NE][IAL INFORMATION Location Address 2 �L KIf n__ _ Owner's Name 1/ 4 M0V S rw /(/ /S/ Mr Address S /� Assessor's Map/Parcel Engineer's Name Dom/17j-'(,��j►'y NEWCONSTRUCTION / REPAIR Telephone# 79�/-/49 / Land Use _&/k//1A4 Slopes(%) Surface Stones Distances from: Open Water Body l(O-D ft Possible Wet Area k1__ - ft Drinking Water W 1 �ft Drainage Way ft Property Line,>31) ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands fn proximity to holes) N V rl T--4 _Z Parent material(geologic) __ IIG J > Depth to Bedrock Depth to Groundwater..Standing Water in Hole: N Weeping from Pit Face N I� Estimated Seasonal High Oroundwatet DETERMINATION FOR SEASONAL HIGH'WATER TABLE Method Used: Jg Depth Observed standing in obs.hole: —In, Depth to soil triottler Aje`4 hj Depth o weeping from side of$b hole: _ __ l[t. ©rnundwatq uAttnent h ft., Index Well#_ _Reading Date: V/4 Index Well levoj-�� factti . �r r�.Groundwater Leval _ > PERCOLATION TIES' mate I&JI � �AYnta �t:6J Observation Hole# 7Tinto at 9" f it ss Depth of Pero YQ_ Time at 6" (41� Start Pre-soak Time @ Y End Pre-soak f. • 2 Rate Min./Inch Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) � Original: Public Health D,vision Observation Hole Data To Be Completed on Back------\' ***3f percolation testis to be conducted within 100' of wetland,you must first notify the, Barnstable Conservation Division at least one(1)week prior to beginning. Qa1S EPTIC\PERCFORM.DOC DE EP.OBSERVA'ITION HOLE LOG Dole# Depth from Soil Horizon Soil Texture Sdil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. onsistency.%oravel) S c S- 13 Z rz u;�Cfj urj DEEP OBSERVATION HOLE LOG Hole#_Z Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. onsisten % ra v ,- ^ 2 A V DEEP OBSERVATION BOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistenev.%Gravell DEEP OBSERVATION DOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. Consistency, i Flood Insurance Rate Map: Above 500 year flood boundary No 4 Yes Within 500 year boundary No= Yes Within 100 year flood boundary No._1X Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the . area proposed for the'soil absorption system? If not,what is the depth of naturally occurring pe ous matorial? Certification I certify that on 11 67, /07— (date)I have passed the soil evaluator examination approved by the Department of Envi onm ntal Protection and that the above analysis was performed by me consistent with the required train' g,experti and ex erience described in 10 CMR 15.017. Signature Date Q:\SHPrrlC\PRRCPORM.DOC TOWN OF BARNSTABLE LOCATIONt .f '`� -22 SEWAGE # VILLAGE ASSESSOR'S MAP &LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 1xy LEACHING FACILITY: (type) >7 f 4 S' (size) NO.OF BEDROOMS BUILDER O O6WNER PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by � � � `,. � - �� ,� 0 �� � � �� COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL.AFFAIRS c DEPARTMENT OF ENVIRONMENTAL PROTECTION RECENED - AUG 2 3 2002 TITLE 5 TOWN ur ksri N< SiABLE HEALTH DEPT. OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: ( A Owner's Name: Owner's Address �&,OL6yao , O�Ce�d' Date of Inspection: Name of Inspector: 77 please print) 1- �.1• e�w-ram '�'�'� PARCEL: T -- Company NameeA d LOT Mailing Address: U i Telephone Number: G09 9 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 asl 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. I am a DEP approved system inspector pursuant Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fa' Inspector's Signature: �' Date: _ � i The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 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 of the DEP..The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments R #` **"This'report only,describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different, conditions of use. Title 5 Inspection Form 6/15/20.00 page 1 Page 2 of 11 �y6 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: �� lqoaw paw& " Owner: Date of Inspec ion: �- Inspectiori`Stimmary: Check-A.,B;C;D or E/ALWAYS complete all of Section D A. System Passes: I'have notfound any information which indicates that any of the failure criteria described in 310 CMR 15:303 or in 310 CMR 15.304 exist.Any failure criteria not-evaluated are indicated below. Comments: . ...... ..� q/4tpi B.- System Conditionally Passes: 'One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair; as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N;ND)in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or.tank failure is 'imminent:System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of,sewage.backup or break out or high static water level in the.distribution box due to broken or obstructed pipe(s)or due to a'broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping.more than 4 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 obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL.INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A.' CERTIFICATION(continued) Property Address: Owner: Date of Inspe on: / 006z .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 public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(4)that the system is not functioning in a manner which will protect public health,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 any).determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a. surface water supply or tributary to.a surface water supply: The system has a septic tank and SAS and the.SAS is within a Zone I of a public water supply. The system has a septic tank and SAS.and the SAS is.within_50 feet of a private water supply well_ _ The system has a.septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a. private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified.laboratory, for coliform bacteria and volatile organic compounds indicates that the well.is free from pollution from that facility and the presence of ammonia nitrogen andtnitrate nitrogen is equal,to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.. 3. Other: 3 Page 4 of l l 'OFFICIAL INSPECTION'FORM-.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner Date ofInspec on: D. System Failure Criteria applicable to all systems: . You must indicate"yes"or"no"to each of the following for all inspections: Yes Nq a _ ✓ Backup of'sewage into facility or system component due to overloaded or clogged.SAS or cesspool _ 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 invertdue to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than ''/z day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number / of times pumped _ J Any portion of the SAS, cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface / water supply. P . 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. [This system passes if the Well water analysis, performed at a DEP certified laboratory, 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,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] (Yes/No)The system fails. I have determined that one or more of the above failure criteria.exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system mustserve a facility with a design flow of 10;000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: The following criteria( o apply to large systems in addition to the criteria above- . ) yes no 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 II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D`above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with.31.0 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 10 Owner:9jW1X4X- 4L&-A Date of Inspe ion: �� 4 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No Pumping,information was provided by the owner,occupant;or Board of Health (/Were.any of the system components pumped out in the previous two weeks ? Has the system received normal flows in the previous two week period ? V Have large.volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined?(If they were not available note as N/A) t _ Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? Were all system components,excluding the SAS,located on site Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction,dimensions, depth of liquid,depth of sludge and depth of scum? _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes no Existing information.For example,a plan.at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] 5 7 Page 6 of I 1 OFFICIAL INSPECTION.FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:9 (� !,4 Owner• _ Date of Inspec ion: / >a FLOW CONDITIONS RESIDENTIAL ✓ Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 31 O.CMv J5.203(for example: 11:0 gpd x#of bedrooms):3-2151. Number of current residents:_(• _ Does residence.'have a garbage grinder(yes or naj:.� Is laundry on a separate..sewage system (yes or . no� if es separate ins ection required] l Laundry. stem inspected(yes or no�,/ - Seasonal use: (yes or no / (usage ears � ��/ P )) Water meter readings, if available(last 2 X - a d : 00"7�" e 0�-`z�elnx�q Sump pump(yes orno)/—� Last date of occupancy: �,AL�- "eat-1 COMMERCIAL/INDUSTRIAI"(C- , Type of establishment Design flow(based on 310 CMR.15.203): gpd Basis of design flow(seats/persons/sgft,etc.): 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/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source ofinformation: / Was system pumped as4paof the nspection(yes or noL If yes, volume pumped: gallons--How was quantity pumped determined? Reason for um in P P g 7OF SYSTEM ptic tank, distribution box, soil absorption system Single cesspool _Overflow cesspool _:Privy Shared system_(yes or no)(if yes,attach previous inspection records,if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank —Attach a copy of the DEP approval Other(describe): Ap roximate age of all components, date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or o): 6 Page 7 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner:. " Date of Inspe on: / U� BUILDING SEWER(locate on site plan)L--/X- - Depth below grade: Materials of construction:_cast iron _40,PV.0_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints, venting,evidence of leakage,etc.): SEPTIC TANK:— ocate on site plan) Depth below grade: 30 Material of construction::],�doncrete,_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:— Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) _ Dimensions: Sludge depth: �� Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness:�� Distance from top of scum to top of outlet tee or baffle: 3 ), Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined! ( 4.,V Comments(on pumping recommen tio�and outlet tee or baffle condition,,structural integrity, liquid levels related to outlet invert, evidence of leakage,et .): vp•r GREASE TRAt/j(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(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 7 Page 8 of I I OFFICIAL°INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: ! C M Owner: Date of Inspe ion: (ool TIGHT or HOLDING TANK(tank must be pumped 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 present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches, etc.): DISTRIBUTION BOX:-jZ(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: �, � Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of kage into or out of box, etc.): av- PUMP CHAMBER (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.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: A Owner. Date of Inspe ion: lb UoL SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: leaching chambers,number: leaching galleries,number: leaching trenches, number, length: leaching fields,number, dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, 07 CESSPOOLS;-�(cesspool must be pumped as part of inspection)(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(yes or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIV`�. 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.): 9 Paae 10 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY-ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 17 Owner: C1L Date of Inspec ion: /s,C;)o SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.Locate where public water supply enters the building. t c�g 1 i 10 Page 11 of 1.1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspe ton: CIT SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water �� feet' .Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with,local.excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: y D/` dyz Perm t{dumber: Dare: Completed by:. ; HiIGH GRO-UND-WATER LEVEL COMPUTATION Site Location: 7 /1-d rle" , Lot No.. Owner: i9 _B3�_� Add-ress:. Contractor: ti1i � Address 7 � /? GfS �° / • Measure depth to.water table. to nearest.1./10 .................................... .Dare .. .... - montFi/day/.year -- S:T,E,P 2 Using.Water-Level.Range Zone i and Index 1Nell;..M:a.p:locate site and,determine: C 3 I OAppro.priate.index wel'L.............._..._..........J ®:.._.......-.. 16 Water ievef rrl.ge zgne.,._............................ _.-._._.......,-,--.. S Using-month ly.rapark"Curreni I- Water R.esources:Conditions" determine current-depth-to -7/�L Ii) water.Ievel for'indaz wel ....-....................... l month/year i. STEP. s• Using Tabie.of.Water;l.ev:ei Adjustments for index vJell (STEP 2A),:curreent depth' I' to water"-level for.index well (STEP 3-)', and-water-level Zone (ST EP•2B) determine water-level adjustment .........................,-.........:...........:....-....-................ _..:-.... ..__..<. " STEP: 5 =sti"mate-depth to:high water by subtracting th.e water level adjustment.(STEP 4`) from measu-red..depth to•water Z7 �• level-at si�te.(STEP"1).----•---.:.............................. .................................................................. Figure. &^Rp,,,Df.lodudble ,oillpu'ati l Iv 1.IC d 'a /Po E� 'lcocl � act.. a� LOC&.TION ' SEWo.6.4E PERMIT UO. VALLAGE IWSTaLLER S VI&ME ADDRESS -- BUILDER5 L1 &MF- AD-DRES_S _DATE-.P-ERM T ISSUED --D AT_E---COMPLI /�,t�ICE ISSUES � 5 r f a� is C t ii r t'a OF Al Z,Or ROBERL 9GN� No...... THE COMMONWEALTH OF MASSACHUSETTS A .A Flo.11944�0 � ISTS - BOARD OF HEALTH NALEN� ....... TOWN...........OF................BIMISTABLB.............................................. Appliration -for Uiii vital Worho Tint itrnrtion r uti Application is hereby made for a Permit to Construct ()C) or Repair ( ) an Individual Sewage Disposal System at: ................. keb3r_.R�_Ughpaia�t--Roads---------------------••- .................... tot--#23.......................... ................................. Location_Address or Lot No. MexcA__8a ty._Tralsti. Bair oaclDaz. buzy..--------"------------------•--•-•--••------ 44 wner Address ......................................................... Install r Address dType of Building Size Lot....20. -000..._.._._.S feet U Dwelling—No. of Bedrooms--------------tbio-----------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) p' Other fixtures ................................................ W Design Flow.............50.._..___._.._._________._..gallons per person per day. Total daily flow---------200------:_-_-----_------------gallons. WSeptic Tank-1 Liquid capacity 1060_-gallons Length................ Width................ Diameter................ Depth--..----_-.----- x Disposal Trench—No. .................... Width.................... Total Length-------------------- Total leaching area--------------------sq. ft. Seepage Pit No..._...OriG...... Diameter-------10_.nO"Depth belo}�� it � _�0-It..... Total leaching area....?.67-------sq. ft. z Other Distribution box ( ) Dosing tank ( ) dG �" Al 3— 73 '—' Percolation Test Results Performed b Robert G. McGlone R.P.E.-•-•------ Date____ a y --------------------------------- ___- -4/3/73-------------------.. a Test Pit No. 1____2-_____--minutes per inch Depth of "lest Pit____________________ Depth to ground water-------none.-.___. G4 Test Pit No. 2----------------minutes per inch 'Depth of Test Pit.---__-_____________ Depth to ground water---------------.-------- 0 1�sting_..Surface---KL-ev.,---JOO-.0©-Eleu...97.0 Ldo0--- atxl_and•-�h soi•1-----la-ev.--9 0-7-.0 - Description of Soil__-F1ev.-__96.50--_Bro7,m---subsoil___,wi_th__trace--of--clay__-Elev.--96-.-50-a-ev.96woo_ V -Clay_.Eleu.__-96.00-El-eu.•-90.Q0--Mecl3:um..Eoarse,_Gravel---nev.-.-901X0---$ot-tors--o-�'--p=it----------------- W ,:Ng__water.I aund 4/3/73 PexC,�__� te_-1!!�2__Mins. C°� _ u 92.OD U Nature of Repairs or Alterations—Answer when applicable-----------4 ------------------------------------------------------------------- ----------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Cod — The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b iss by t e bo d of ealth. Signe --- Date Application Approved By. Date .Application Disapproved for the following reasons_________________________ __________________________________________________________________________________-- Date PermitNo.......................................................... Issued........................................................ Date —� S r ROBERT f. g G. yo No THE COMMONWEALTH OF MASSACHUSETTS A�,Q lio.11944�0 BOARD OF HEALTH OSONALE ....... TUvAl............OF...............13ATa!"�r., � , r:,... --------- ---- ------------------ . pphratiun -for Uhipoiittt Markii Cnnnitrnrtion Vr t Application is hereby made for a Permit to Construct (X ) or Repair ( ) an Individual Sewage Disposal System at: ----- ------•----•-----_----- f__ �'f --------------•--•-----------••-•-•--•••--•-•-----••-- Ayy�i/� Rp�j Locatiooy�n--Addd{ress y��q��, p (�;y(��/� yv}�orj Lot No. ________________ 42'J�NIC._AYPJSI� ...2.1_11.A•iF.,...__._____.__._.._..._._.__....................................... ....... -"�„j__^•Swr'^`+_______=_]9'A3'.? Sy�___----____-__________-________________________ wrier --• Address w 14 __ t` k1al r Address UType of Building Size Lot---2a ------------Sq. feet ., Dwelling—No. of Bedrooms..............two.......................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) 0.' Other fixtures ---------------- -------------- - c�l 200 w Design Flow____________ ............................gallons per person per day Total daily flow..•.....-....... .........._...._....._.....gallons. WSeptic Tank-y-Liquid capacitv!MO_.gallons Length---------------- Width._--_-----_-- Diameter_-.--...-.___-__ Depth_:_._---__._-_. x Disposal Trench—No-____________________ Width.................... Total Length--_--_--_--______-_. Total leaching area---------------------sq. ft. Seepage Pit No------- 1!0------- Diameter-------In!!-!0f1Depth bel gw i A�_-'�!!._____ TotaLleaching area----26!-------sq. it. z Other Distribution box ( ) Dosing tank ( ) ©P" �"`3� —S ' a Percolation Test Results Performed by......X*g _Q,,,_._jjcQ1t3:nf'_.R.�'s :....._.___. Date-.-✓ o-a...................._ Test Pit No. 1----------------minutes per inch Depth of Test Pit..................... Depth to ground water......X404113._.--._. - -" (J, Test Pit No. 2----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water------------------------ 1:4 l .St:f ng; _9 rf.nn j+ _nar* 1!1!�=��w;'aI atI'7 �'��: �1 T,� r+ r?srf of C''aaS�,nt�i-9---T"t• •csr*--07`A .. OA� Description of S�oiLl_.r r �? +... , Z...tTr!�11,�t s,"t_titt�7 +>t ' �i' + +"3,r^ s.•_t?F,� {?®?�'3.Fssge:=.. �� W ._!J7 r' _ �'.LA? "fit '� •O9C __ /n� pt p _1_!!'Tt__1`'i !w rf;e A yl 1 3�r L)(1 f4J't __'�?r.+F i sn F' tie7�y / \ ._•_ -••✓ .j !! -r..• b5-f E? �.._.. .74 .<::«v U'J +J1.-•>v1 >s J JQi3�--•�.D.L.•'j:•_ST.._ .. w c►..yTa e, .__f r�--- 413/73----- �_.`�_ev...92100-------------------------------------------------------- VNature of Repairs or Alterations—Answer when applicable.:--_-----------------------------..................-------------------------------------------- Agreement The undersigned,agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Co The undersigned further agrees not to place the system in gpµ p operation until a Certificate of Compliance has b n is by e bard o�health. Signe .... ._ ... _ - . Date Application App'oved By- . i _------•----------- Date Application Disapproved for the following reasons:-----•----------------- --------------------------------------•--•--- --------------------•-------_----------- ---•--••----•---•-••-•-.._•.•...••••--...-•--------••--•--------•---•-------------------------•-----------•-----•-'•-------------------------------•-----------•--------- ---------------------•--_----- Date PermitNo. -•••------------................... Issued .................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH j:r ........:..:.:: ......OF..EARNSTABs7��".+r'....................:................................ fferttfiratr of mvmptianrr' TVIS IS TO C TIF That the Individual Sewage Disposal System constructed (X ) or Repaired ( ) by...... t------------- "y fu.• Installer at..............1, G••- l_nkfiy--And—.1A.9h.-PoiAt.- 2Aids---- ................... has been installed in accordance with the provisions of Art' . I of The State Sanitary Code as described in the application for Disposal Works Construction-Pe _ Vrmit No. VY--------------- dated'..l _-l_-7 - ........ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE • SYSTEM WILL FU CTION SATISFACT Y. DATEInspector---- ..._ ---•--- - --- --------- ................................ THE COMMONWEALTH OF MASSACHUSETTS t BOARD OF HEALTH ......' ...................................... No.._.__'T-"/.. FEE. --------------- 'D somiat Workii Tmitrnrtton Vrrntit Permission 'is`hereby'granted........ Y`gt) �teaitv•'i~ "qa -----------------•----------------------._._.-_.-._--------- to Construct ( X) or Repair ( ): an;Individual Sewage Disposal System at No. o __ ? _ akE a AYI&IMgh1 �3zit; - --------- --------------------- Street 4 as shown on the application for'Disposal Works Construction mrt o ___- --__ Dated"..fsz"........................... ,.% /77,6 Board of Heal DATE7------------------------------------ FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS .. U..Tr urjjecr 017t J,Ili NU. o,o < �3 yam, .o 0 0 41.±- a � � o 4-1 c} LO .` r -- GE �y 7744r r'NE LoT 23 . h'oK/ti/ NE2Eo�.! CGt��i4'JCS K/i7N 7"h�E g 00, 1 aW �Au,S 06' Ti'/,� 7-a VL/Ad 0,'= L A i XO LoV eT N 0. P, (, BA-tTMZ ii N`(L OJC. 4>47L Nov 2G /y7 i2e6(SrtxCS�:) LAN'o St1v,)t1cz'5 I t�� c-5i�e-V iLLc� . AA.A 4�,S