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HomeMy WebLinkAbout0030 LAKE SHORE DRIVE - Health 30 Lake Shore Drive Marstons Mills A =0301u7 .......... ---------- -------------- �7_ F 1— F17 77F7 Ak .......... I 71 ---T--- ----------- -4- FL_T, -4-_1 ........ ------- .................. ............... .......... A7 _ �____1_ r fi I- 7� _� _ _-- __ _ _ ___ _ ____ _ : _: _____►__ _____ - --_- ........... 7, T J r7 o oo ool— r . �_ I k I- . .._t._ L_ 1 l .�. r -� - I -- - - - - - -� --- -- .._ . -- - 1'- - f- '-- - i - .............. .......... I l.. _ .............. ..... ............ ............. ........... ....... L. 01- 00- -El E-r EL tj -tF .......... -4--l-4- i -- - - ----- - - - - - - _--- - -- -- -_ __ ----- - - -- ---- - - - - - -- -- - - - - ._..._ _ ---- -- - - - - - I. FT- ............ - T.-.J.-.7..;. ------------ ......................... I e . L lI - - r L t - _ - 1 -- - - .. - --- - - - - - - --- - ___ ..-..-...-..-....-..... .---..-- _ 4 , , _ _..�._�._..,.__r. __,_..�.I_. ...___.__... _ _ __..,..__ i____. - ; , ! � � j --�- , --;-L- - -�- =- ---ice ---�--{--•------ - ----�- --{= - - -- t--; -f- - --- -t--�--- -� 7- .L-I-- '1-� -7--.._.'-.I �_--, -----..,.�..L.--"r-�--;-� -�-�-�-�--L�._L� ! ;-L! .--��-- I -�- --I- _!_._�_L..� - I--- --r� ._I-_ _ ---- I - - - --� ---•.�_I Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form Inspection results must be submitted on this form or on the official Title 5 Inspection Form dated 6/15/2000. Inspection forms may not be altered in any way. A. Certifications 1. Property Information: 30 Lake Shore Dr. Property Address David Clemence Schriner Owner's Name same Owner's Address Marstons Mills MA 02648-1335 City/Town State Zip Code Date of Inspection: 2/1/07Date 2. Inspector: Matthew L. Childs Name of Inspector same Company Name 4 Orchid Ln. Company Address W. Yarmouth MA 02673 Cityrrown State Zip Code 508-989-1479 Telephone Number < j C- Certification Statement: =t I certify that I have personally inspected the sewage disposal system at this address and that they; information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of ol3 site sewage disposal systems. I am a DEP approved system inspector pursuant to!SectionA5.346 of Title 5 (310 CMR 15.000). The system: 7TI ® Passes ❑ Conditionally Passes ❑ Falls ❑ Needs Further Evaluation by the Local Approving Authority 2/1/07 Inspector's Signature Date 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. ****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. Schriner.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 1 of 16 i - Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 30 Lake Shore Dr. Property Address Marstons Mills MA 02648-1335 City/Town State Zip Code David Clemence Schriner 2/1/07 Owner's Name Date of Inspection Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found 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: passes 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.wi►I 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: N/A Schriner.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 30 Lake Shore Dr. Property Address Marstons Mills MA 02648-1335 City/Town State Zip Code David,Clemence Schriner 2/1/07 Owner's Name Date of Inspection B) System Conditionally Passes (cont.): ❑ 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: N/A ❑ 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: N/A 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)(b)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 Schriner.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 3 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface w i^� ace Sewage Disposal System Form A. Certification (cont.) 30 Lake Shore Dr. Property Address Marstons Mills MA 02648-1335 City/Town State Zip Code P David Clemence Schriner 2/1/07 Owner's Name Date of Inspection C) Further Evaluation is Required by the Board of Health (cont.): 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 1 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: N/A **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. 3. Other: N/A Schriner.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 4 of 16 f Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 30 Lake Shore Dr. Property Address Marstons Mills MA 02648-1335 City/Town State ZipCode David Clemence Schriner 2/1/07 Owner's Name Date of Inspection D)System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® 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 invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/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: ❑ ® 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. ❑ ® 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. Schriner.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 5 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form } Not for Voluntary Assessments ;w Subsurface Sewage Disposal System Form A. Certification (cont.) 30 Lake Shore Dr. Property Address Marstons Mills MA 02648-1335 City/Town State Zip Code David Clemence Schriner 2/1/07 Owner's Name Date of Inspection E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. 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 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Schriner.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form '4?N B. Checklist 30 Lake Shore Dr. Property Address Marstons Mills MA 02648-1335 City/Town State Zip Code David Clemence Schriner 2/1/07 Owner's Name Date of Inspection 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? ® 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) ® ❑ 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: ® ❑ 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)] Schri'ner.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information 30 Lake Shore Dr. Property Address Marstons Mills MA 02648-1335 City/Town State Zip Code David Clemence Schriner 2/1/07 Owner's Name Date of Inspection Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 gpd. Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] 0 Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 years usage d N/A Sump pump? ❑ Yes ❑ No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: N/A Design flow(based on 310 CMR 15.203): N/AGallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): N/A Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: N/A Last date of occupancy/use: N/A Date Other(describe): N/A Schriner.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) . 30 Lake Shore Dr. Property Address Marstons Mills MA 02648-1335 City/Town State Zip Code David Clemence Schriner 2/1/07 Owner's Name Date of Inspection General Information Pumping Records: Source of information: owner Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: N/A gallons How was quantity pumped determined? N/A Reason for pumping: N/A 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) ❑ 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): Approximate age of all components, date installed (if known) and source of information: Installed in 1989 per disposal works construction permit on file at Barnstable BOH. Were sewage odors detected when arriving at the site? Yes No 9 9 ❑ Schriner.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of.16 I Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments �M Subsurface Sewage Disposal System Form C. System Information (cont.) 30 Lake Shore Dr. Property Address Marstons Mills MA 02648-1335 City/Town State Zip Code David Clemence Schriner 2/1/07 Owner's Name - Date of Inspection Building Sewer(locate on site plan): Depth below grade: 1.3' feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints,.venting, evidence of leakage, etc.): All in good working order at time of inspection. Septic Tank(locate on site plan): Depth below grade: f e Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of ❑ Yes ❑ No certificate) Dimensions: 8'x5'x5' outside 1000 gal. Sludge depth: .4 Distance from top of sludge to bottom of outlet tee or baffle 3.5' Scum thickness .2' Distance from top of scum to top of outlet tee or baffle .4' Distance from bottom of scum to bottom of outlet tee or baffle 1' How were dimensions determined? tape measure Schriner.doc•1111004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 10 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments �M Subsurface Sewage Disposal System Form C. System Information (cont.) 30 Lake Shore Dr. Property Address Marstons Mills MA 02648-1335 City/Town State Zip Code David Clemence Schriner 2/1/07 Owner's Name Date of Inspection Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank shows no signs of leakage and was pumped as maintainance at time of inspection. Grease Trap (locate on site plan): Depth below grade: N/A feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): N/A Dimensions: N/A Scum thickness N/A Distance from top of scum to top of outlet tee or baffle N/A Distance from bottom of scum to bottom of outlet tee or baffle N/A Date of last pumping: N/A Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): N/A Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: N/A Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): N/A Schriner.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of 16 j Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form �M C. System Information (cont.) 30 Lake Shore Dr. Property Address Marstons Mills MA 02648-1335 City/Town State Zip Code David Clemence Schriner 2/1/07 Owner's Name Date of Inspection Tight or Holding Tank(cont.) Dimensions: N/A Capacity: N/A gallons Design Flow: N/Agallons per day Alarm present: ❑ Yes ❑ No Alarm level: N/A Alarm in working order: ❑ Yes❑ No Date of last pumping: N/A Date Comments (condition of alarm and float switches, etc.): N/A Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0.0' Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box is level with no solids carryover or leakage at time of inspection. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Schriner.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 12 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form �N SVV C. System Information (cont.) 30 Lake Shore Dr. Property Address Marstons Mills MA 02648-1335 City/Town State Zip Code David Clemence Schriner 2/1/07 Owner's Name Date of Inspection Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): N/A Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 2 ❑ 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, etc.): 2.6'x6' precast pits with 2' of stone had 2' of water and showed no signs of hydraulic failure. Schriner.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 13 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form 9 p .Y C. System Information (cont.) 30 Lake Shore Dr. Property Address Marstons Mills MA 02648-1335 City/Town State Zip Code David Clemence Schriner 2/1/07 Owner's Name Date of Inspection Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration N/A Depth—top of liquid to inlet invert N/A Depth of solids layer N/A Depth of scum layer N/A Dimensions of cesspool N/A Materials of construction N/A Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A Privy (locate on site plan): Materials of construction: N/A Dimensions N/A Depth of solids N/A Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A Schriner.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 14 of 16 I Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 30 Lake Shore Dr. Property Address Marstons Mills MA 02648-1335 City/Town State Zip Code David Clemence Schriner 2/1/07 Owner's Name Date of Inspection 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. Lake Shore Dr. W/S #30 A-147' B-1-22' A 2-61' B-2-44' A-3-71' B-3-46' A-4-31' B4-30' O O 4 3 Schriner.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 15 of 16 l Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 30 Lake Shore Dr. Property Address Marstons Mills MA 02648-1335 City/Town State Zip Code David Clemence Schriner 2/1/07 Owner's Name Date of Inspection Site Exam: Slope Surface water Check cellar Shallow wells Estimated depth to ground water: Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 10/23/89 Date ❑ 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: Checked test hole data from system design plans. System was installed within reasonable limits and has adequate groundater seperation. Schnner.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 16 of 16 TOWN OF BARNSTABLE OCATION30 "�/if .�!`/CJ/' SEWAGE # t VILLAGFIWC ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO.-I SEPTIC TANK CAPACITY x r LEACHING FACILITY:(type) 1:, (size) NO. OIL BEDROOMS PRIVATE WELL OR PUBLIC; WATER BUILDER OR OWNERe� L IYP YC A /f DATE PERMIT ISSUED: -2- DATE COMPLIANCE ISSUED VARIANCE GRANTED: Yes No r � � ___. A r. °�Ac;1C � � r ,>`�` �a ;.. � `�� ��� �6 t i �� �f N�'� �1 �,;. r Fitz THE COMMONWEALTH OF MASSACHUSETTS /a 7, BOARD OF HE T . � ����` H ------...... .----.._.O . . . ...----------------------------------------= Appliratiun for Disposal Works Tonsftvdiott V rmft Application is hereby made for a Permit to Construct ( ) or Repair G'/�an Individual Sewage Disposal System at: .......... a ._..........1. -!-C�_L1LL/.h... C_..E_o.ca�tilOo w�t_rl.�....r..r�.e.s.N.e`1 2� _- - ... ................... ...... 1-.. T.'t--N.o ..-..--.-.-- .-.-._.. s N �'j'. . �� :.. . -...... ........................_. ner Address .............................. ... ........._...._...........----- Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms................ ......_.......Expansion Attic ( ) Garbage Grinder ( ) a'4 Other—T ype of Buildin g ............................ No. of persons.......... Showers ( ) — Cafeteria ( ) dOther 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. 3 Seepage Pit No..................... Diameter.................... Depth below inlet--.................. Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) 0.4 Percolation Test Results Performed by.......................................................................... Date........................................ a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ LL, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ OG ....---•-•---•-••-------------------•-----------•--------------•-•-•....---...............-----•----......................................................... 0 Description of Soil........................................................................................................................................................................ U --•------------•--------------------- -------------------------------•---------------•------------•--------------------------------------------•---•-------•----•--------•----...------------.------ W .............................. c _.. c --------------....._.._..._. ..... ......................................... ...... U Nature of Repaik sor Alterations—Ans er when pplicable/T �'�! l ' ................ - j..-........................�.. ... __..................---_:__............................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITL U 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 b e bo of health. Signed..--6AJ.. _.:'c/+ -•----.... l . Application Approved By....... :..... . . ate Application Disapproved for the following reasons: --...-- ....................................................... ......-••-•-------------------------------•-----•-------......----------...........-----.•..........----•-•---.......---•--•--•••----------------•----................................................. 6" <';` PermitNo.......P._ -�- ��--�------------------- Issued....................................................... _. Date a♦1- No. ':' :' "r. THE.C'OMMONWEALTH OF MASSACHUSETTS '03� f ad BOARD OF HEALTH s:..-..oFL,l Iw 5� . ., vArtttiun fur i ispnuttl Works Tonshntiun rrrmit Application is hereby made for a Permit to Construct ( ) or Repair (k*J'an Individual Sewage Disposal System at: LA/65 ca- _ �,EAe� c` - rIsstj e rt . ............ 5° �v .j......................................� __.�......_...'.. �� Owner ! Address . lC / a ... 1.....,....0 u_ ._... '.:<�............................................. �.��w...---�:.................---.....----......-----------....---....._.. Installer Address Type of Building Size Lot............................Sq. feet aDwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures .................................................................................................--------- ------------•- .......---....----------- - WW �`i)esign-Flow...................:'.-.-.--=.::=:..._.::.gallons per person per day: Totab-daily,flow.._..__......-_......._..........I..........gallons, WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) a11 Percolation Test Results Performed by.....................................:.................................... Date...................................... .4 Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ fi Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ CA ` .._..._r..... ----------------------------------------------------------- Descriptionof Soil....-•----•-•-•-••------•-•...._....--•......... .........•........•--•---•---•....._....-•------••--------.......•---..................__................._------..... V --••------------------•--•-•--.........--•---•......---------.=•--•--.........-•---•--.........----------•-----....-----•-•-------...-• -----••---•--•--•-•--•--...........---•------ W ---•----------------------------------------------------------- - U­.,, Nature of Repairs or Alterations—Answer when applica .. ble...._�v�e�..........ICXI S�/�. / ��,e NK ---- Agreement: ................r................................................................................ The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITI.s ' 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 a boa • of health. Signed. .... ........................ Application Approved By.......� r�Y X f 4 �__________ t-/!� .•��Se. .f Itte Application Disapproved for the following reasons:--------------------------••...--------------••--•----••-•---•-------...........--•-•----.•---.............. __.. ----------------•........------......---••-......----••--•-----•-•------•_. ....•----... .... ..._..------------•-•--•---•--.....----••---•--------•...-----•-••-•-----..........--- _!�... � Date Q ti PermitNo..... , ---- ----------• Issued..----•---••-.....-------------•----•--................ _ Date w 4 v THE COMMONWEALTH OF"MASSACHUSETTS,. ., y - ��,�,,�' BOA�R,-D� OF HEALTH. 1 .............oF, .... ...........N ..................................................... Trrtifiratr 'of Tumphanr_ . THIS IS TO CERTIFY, Twat-1 he Individual S w.zge Disposal System constructed ( ) or. Repaired (114 by-------- -••---------------•----------------- .....e�...... .�2..... -�......................................................:......................................... Installer at.................3 Q....L- 1��e ��� ------D P,-:------------------- �-- ...- .................... has been installed in accordance with the provisions of TITIZ 5--of The State Sanitary Code as Oescribedjin the application for Disposal Works Construction Permit No..--.. ryf^._ dated....-.' THE ISSUANCE OF THIS CERTIFICATE SHALL NOT EE-•CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE... .:_/ ..' .........................................._...... Inspector..-- ril .-.-.v' --v..........----.....-----........................ THE COMMONWEALTH OF. M;kSSACHUSETTS BOARD OF HEALTH .............0;: RXr,....S..11f.r/< ..................................... A,, No... ............ 6 F$E�.................. Disposal urRu Tunutrudiun lirrutit Permission is hereby granted..... C/ _7• •..... •... r... .. ........................ ......... to Construct ( ) or Repair (� an Individual Sewage Disposalystem at No.:------------- ._.I.,t1; ...: !� �� Y110/ �l S ....... Street p as shown on-the application for Disposal Works Construction Permit NO.-4-f!' 'ated...Z!gl .��., -------------•----..................._....--.••---.••.. DATE. C.-/ — .`L= .._.................................. Board of Health LO- CATION 3o EWAGE PERMIT NO. VfLLAGE — T INSTA LLE 'S NAME i ADDRESS BUILDER OR OWNER DATE PERMIT ISSUED 11�1z-r� DATE COMPLIANCE ISSUED G \ INI pisO"`.�• •�+ a .� C-7 No......... L.._ F�s.... .5.. . THE COMMONWEALTH OF MASSACHUSETTS BOAR® O �-I E L I-� .............. . . ........-O F......... ... :... ._................... Applira#ion for Uispvii al Works Cinitrurtinn Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: t.-i --•......................... ^ Location-Address or Lot No. JJLIA . ...........................•----------........---..............---•--............................. Owner r Address aF1 ................. .................................................................................................. Installer Address QType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms...........................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons...... ................. Showers — Cafeteria dOther fixtures ----------------------------------------------------------•--••-•---------•----------•---•-•-------------------•---•----------............._.....•---• Design Flow3.5 -...�...............gallons per person per day. Total daily flow----3� ?......_.._..__..............gallons. W M0 WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length..................... Total leaching area `:l.......sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other'Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed b .................�-M5....A 5�:. . •_ Date._..... _._... . .. Y ll - aTest Pit No. 1................minutes per inch' Depth of Test Pit.................... Depth to ground water......................... fi Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.......................... ,..O Description of Soil-------5-�---d �• •. ` f -- l Z - x x -----------•--- -------------------•-•-•-•----------------••------•----•------•----•---••-•••-•••--•----••-•---------------------•--- ----------=-......-••-........................................ U Nature of Repairs or Alterations—Answer when applicable..................... .. ......................Y*­*...*---- ............. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iiT ;,,. 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 of health to Si ed. _. . .....J .._. .................... Date Application Approved BY------11-44114,f..... .. . ..G7_.t �-------------------- .... ..� '.Date Application Disapproved for the following rea ons------------------- ..-----------------------•-•-...-•---------------•.•--•----•-•-•-----.........L __ t .................................................... ..............................................•------------...----- Date PermitNo..............................................�`��. . Issued_....................................................... .. Date No.._.... FEE.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD g HE LT j1''f!!/ . ------.OF....... ... .. --- ..... .............................. Appliration for Disposal Murks Tongtrnrtion Prrmit Application is hereby made for`a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ................_.....---...._......-----............-•- ....................... ....................................................--.-......................................... . Location-Address or Lot No. (\1 J�.�1 a~...�1 h.....1!"T..1 C •' .._�...)F.'-i n l.... ... ...................................................................................... Owner Address ?a ...........................(� `t�QC17�....t'.. !�� ! lr.��.?-�'!.... Installer Address d Type of Building Size Lot----------------------------Sq. feet U Dwelling—No. of Bedrooms............*•�...........................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons 2-.................. Showers a YP +, g ---------------------------- P ( ) — Cafeteria ( ) dOther fixtures ------------••• -•------•--•-----•---••----•--------......••------•--••-------•-•----••-------•-•...... -------_.... ....•••... Design Flow. ..��- ................gallons per person per day. Total daily flow.... :.......-------•....................gallons. W ' 1:4 Septic Tank—Liquid capacity:x2..gallons Length................ Width................ Diameter________________ Depth................ Disposal Trench—'No. .................... Width.................... Total Length.................... Total leaching area..__"-.A........sq. ft. Seepage Pit No.................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) a Percolation Test Results Performed by................' MS ` 55C-C . ......... Date....... ` . .................... Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ r.4 Test Pit No. 2................minutes per inch Depth of Test Pit....... ........... Depth to ground water........................ a ................................; J- - O Description of Soil...----5 -* . .....A!t. F .w .::---.. �? ..� ---. .. ... ►. 1. ",� -A W UNature of Repairs or Alterations—Answer when applicable_......_ ............. ................... ..(.r��t\1 =1?G i.n-�------.�(= -•--• r�'�?� 'J• ... .:_ (::?"�_ 1 S t 1"'��' t . ................ 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 of health. Si ed ------�':_.r-(.. ...o,�la------ �i�r�"t Yut '. .._�.�._��..�.��.._ j/� Date Application Approved By......,� i... � '�' �." / Date Application Disapproved for the following reasons:.....................V .............................. ..._._.._.» ..............•------------------•----------•------...--------•--..........---------------------..........__..........-•-•-•••-•------••------••-...••-••----•--••----••---••-•------------•-••---•-_..._ Date PermitNo......................................................... Issued_......................... ............................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD O HEAL 1 ........::_. .... .. ..............OF......... ........ ' .............. t CIrrtiftrttte of Toutplttanrr y rsI�I T CERTIFY, That the Individual Sewage Disposal System constructed ( or Repairedby / R. . ihstaii = .... ...---- ------- �" •"` - - r ------•. at has been installed in accordance with the provisions of T7 .f/5 of/ e State Sanitary Code as described m the application for,Disposal Works Construction Permit No.- -..1�tt-- ----------- dated_ f........ ... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT B�'CrONSTRUE ' AS A GUARANTEE TWAT,.TH.E SYSTEM WILL FUNCTION SATISFACTORY. DATE................'............................................................ Inspector...-. `' THE COMMONWEALTH OF—MASSACHUSETTS �' �� BOARD O HEALTH S / . ...OF........... r.....--• ..................................... v` J No...........�t..`.�� FEE........................ Btspu, at Wor Tons#rudion rrnti# ; Permission i hereby granted.. 0 _t._ """" Ct ... to Const ct ) r epair ( an In 'vid 1 Sewage Disposal Systll at No.: • r l ,.` "J'k'.Y a t ?. .... �' �'X:�.de�S' Yr.--...... 4' 1' ._.1-" t /-�............ Street } as-'shown on the application for Dis o'sal Works Construction P t No. Dated. ass pp p F ! Board of Health TE---- ' '-_' =.a.......................... ........... FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS ' .•tea,. ym.;x..;< »,..e.,.;b. r_.r.....•.,_ .mraew:� h.,..-.a, rf, Y.,.:.. �ysrs,�:. ,•.•e+.�. r'•+s,.v.�.. •y.�. u., .rfK^'"`� z->_ro•._w: '. _. ?-•an...._-. '-.ter-• "�'1+•":k ......,w. ..zx•^r .. ,. r•._�._....s'._.._�....-,-..„.._.._...-... ._... .e-.<-..�...._,.... _..d..�. ..•...-.. ...-_......y.. 4._�>��..�,...,,..�._....•..•.--...__..•..,.•-�•._..e,»-.._,... ..•.....-»-.sue........._......_ ......_,f�:.,�....� r41 ♦i.4�7. .! i�:.. / Q7 .(s.r. 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SITE PLAN S' HOW IN'G' PROPOSED CONSTRuc ,r [ ON I e'y, �r�_ is YI/ r r .9 •I <•t• AP 1 D 197 7 B-OARD OF HEALTH DATE- " A G E tJ T I � �4s I SFy�e� z SraAcsar A Vt S ASSOCIA'Ti' ES, INC . } ° PVT REG15`CER D ENGI.NEERS L L A N 0 SURVEYORS i ^4t ` MID-CAPE OFFICE BUILDING - I Z 6 5 ROUTE 28 e. A t -a jz..