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HomeMy WebLinkAbout0406 MISTIC DRIVE - Health 'J6 Mistic Drive _ Marstons Mills _ - A=061 - 031 . f CO>tiLVIONWE TAL - TH OF-SASS ACHL SETTS �! EXECUTIVE OFFICE OF EIN-Ni -i\-,TT f i D` DEPARTMENT �nl NT OF ENVIRONMENTAL Ifl�° PROTF T -C TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FOR-NJ PART A / CERTIFICATION Property Address. 0 10Sf i r.,L OoZ 6 Owner's Name: /Ale-Owner's Address:�6 z!tIljr c+ex o /1/ Date of Inspection: Name of Inspector:(please print) All Companv Name: *kvi' 16FG11 Flailing Address: Qp Telephone Number So7j CERTIFICATION STATEMENT I certify that I have personally inspected the se-vvage disposal system at this address and that the information reorted below is true, accurate and complete as of the time of the inspection.Thep o insection was gerforned based on n training and experience in the proper function and maintenance of on site sewage disposal systems.I am a Ds P :approved system inspector pursuant to�Section 15.340 of Title 5(310 CMR 15.060). The system: � Passes ram, c=Z) Conditionally Passes ' V Needs Further Evaluation by the Local Appro�,ina Autho Y5 � �= —_ Fails Inspector's Signature: Date: / p The system inspector shall submit a copy of this inspection report to the Approving A�_ r c~DEP)within 3l-di or 0 days of completing this inspection.If the system is a shared s yste 'or hasya desB� ow of ab00 r- gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of he DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable and the ap,ro,, authority. nc Notes and Comments This report only describes conditions at the time of inspection and under the conditions of use = time. This inspection does not address how the sys#em will perform in the future undo at That conditions of use. r the same or different Title 5 Inspection Form 6115,12000 hR(7a 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSLSSAfEN-TS SUBSURFACE SEWAGE DISPOSAL SYSTENd LTSpECTIO0N PART A CERTIFICATION(continued) Property Address: ��f�t c ,�ii►-Y� Gt r-5 a S 47," O�6 41'r Owner: 91-S Date of Inspection: / p Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A.A`fhave asses: y not found any information which indicates That any of the failure criteria descri-bed in 310 C'Yi12 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B.^ System Conditionally Passes: /1/ 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. P�7ill 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*_'re existin11 g 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. \D 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(v.=th 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 pme(s). The s--_tem- ? pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: w Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESS:kIE-TS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIO_FOR-.NZ PART A CERTIFICATION(continued) Property Address: Ar v✓t* / S �o�-6�FL� Owner: Date of Inspection: / p C. further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to detern ,e i f he sysem is failing to protect public health;safety or the environment. I. System will pass unless Board of Health determines in accordance with 310 CIIR 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 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«ithin 100 feet of a surface water supply or tributary to a surface water supply. The system has aseptic 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 primate rater 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 stem asses if w y p the well water analysis;performed at a DEF certified laboratory; for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that fac ity and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 pm pro- ded that no ot�e; P. failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: i Title Page 4 of 11 OFFICL4,L INSPECTION FORM—NOT FOR VOL1U7-N '_ARY ASSESSITENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM ENNSPECTION FOR-NI PART A CERTIFICATION(continued) Property Address: Owner: 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 Now _1/ 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 logged SAS or cesspool tatic liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or �esspool iquid depth in cesspool is less than 6"below invert or available volume is less than%z day flog- r/ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).1\umbe- of times pumped V y portion of the SAS,cesspool or privy is below high ground water elevation. t/ An es is within 100 feet of a surface water supph°or iiibutary=to a surface y portion of cesspool or pri . eater supply. _ y portion of a cesspool or privy is within a Zone 1 of a public weLl _ y'.rry 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 Beater 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 forma / (Yes/No)The system fails.I have determined that one or more of the above failure criteria east as described in 310 CIMR 15.303,therefore the system fails.The system owner should contact the Boa_a-d of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flocs-of 10.000 gpd to 15.000 gpd You must indicate either"yes"or"no"to each of the following: (The following criteria 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—it,-PA)or a m?u red 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 systern;oncideie4 a significant threat under Section E or failed under Section D shall i 5.304. The system owner should contact the a ro riate regional. upgrad„the system in accordance w'tL ;10(—'a, appropriate ional office of ` ` the Department. Tit1c � Incnor}inn 1-'nr.r �!t[/7nnn Page 5 of 11 OFFICIAL I?lSPECTION FOR1?V1—NOT FOR VOLU�s7ARY ASSESS-MENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM ENSPECTION FOR'tf PART B CHECKLIST Property Address• Owner: S�- Date of Inspection: Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes Rio/ . Pumping information information was provided by the owner,occupant or Board of Health _V/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--N7 A) fWas the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? v— Were all system components,excluding the SAS, located on site? Were the septic tank manholes uncovered.opened.and the interior of the tank inspected fer 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 path information on the Troffer 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)] Title Tncr�cr+inn r —r 411 G Pin— :1 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTT-ARY ASSESS:TENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIO` FORM PART C SYSTEM INFORMATION Property Address: 1�06 Owner: �est Date of Inspection: /7 p OW CONDITIONS RESIDENTIALj.Pr�w�f ?Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 C_-MMR 15.203(for example: 110 gpd x#of bedrooms):4/W � �T Number of current residents: 0 9 Does residence have a garbage grinder(yes or no): /`0 Is laundry on a separate sewage system(yes or no):� rif yes separate inspection required; Laundry system inspected(yes or no):IV Seasonal use: (yes or no): d_ 2 �� Water meter readings,if available(last 2 years usage(gpd)): 'rj. � Sump pump(yes orn Last date of occupancy: /y CO VVIERCLAL/T DUSTRIAL Type of establishment: Design flow(based on 310 0MR 15.203): gpd Basis of design flog(sears/persons/sgftetc.): g 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 INFOR_NTATION Pumping Records Source of information: Was system pined as part of the mspection(yes or no I ):iK/a f yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: OF SYSTEM —Septic tank, distribution box,soil absorption system _Single cesspool Overflow cesspool Privy —Shared system(yes or no)(if yes,attach precious inspection records,if any) Innovative/Alternative technology.Attach a copy of the current operation and maintenance co�Lact obtained from system owner) tto ve Tight tank —Attach a copy of the DEP approval —Other(describe): Approximate age of all compon ts. date installed(if known)and source of inf, Tmation: Were sewage odors detected when arriving at the site r �S o {yes o. no):/��11 Page 7 of 11 OFFICIAL, INSPECTION FORM—NOT FOR VOLUNTARY ASSESS: ENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM IiNSPECT_7p'4 FORAZ PART C SYSTEM INFOR_8 ATION(continued) Property Address: O 6 �/s4IG ,e i/ Owner: 7L Date of Inspection: /' O BUILDING SEWER(locate on site plan) Depth below.grade: /10`�_ Materials of construction:_cast iron 40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence'of leakage,etc.): SEPTIC TANK: `�(locate on site plan) Depth below grade: lot -Material of construction:_concrete_metal_fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a cop--of certificate) Dimensions: C X /10 6:4//o-1 Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness:LPS,S Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to botto of outlet tee or baffle: How were dimensions determined: /o Xe 4a c c%y'Ge Comments.(on pumping recommendations,inlet and outlet tee or baffle condition; structural intern-it..squid levels as Prated to outlet invert, evidence of leakage,etc.): u..•, h /J first. %h 1,� czv.� -/- ex ,h CON /O A GREASE TRAP:y(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,strucnrral lin-teari =igtii le,P+ as related to outlet invert, evidence of leakage,etc.): T;tlo ; Trrnc t;nr F.r.„ 4/1[/nnnn Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUN'T.ARY ASSES SAINTS SUBSURFACE SEWAGE DISPOSAL SYSTEM IN'SPECTION FORM PA.TtZT C SYSTEM INFORMATION(continued) Property-Address: W �o✓1J �, Owner: _es Date of Inspecfion: p TIGHT or HOLDING T'ANK:/V (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal nberglass_polyethylene oiher(explainl: 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: /""(if present must be opened)(iocate 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 leakage in�s or out of box; etc.): c-- �C PUMP CIL4MBER: �y (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.): s 'z Page 9 of 11 OFFICIAL INSPECTION FORM—'SOT FOR.VOLUINT RY ASSESSA1ENTS SUBSURFACE SEWAGE DISPOSAL, SYSTEM INSPECTION FORA1 PART C SYSTEM IINTFORMATION(continued) Property Address: Y06 /Lli,f'iic oa 64-5` Owner: Date of Inspection: 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: ,JcTc-hing 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.): ohe i 7-' �p� .� �a• K CESSPOOLS: /y (cesspool must be pumped as part of inspection)(locate on site plan) \umber 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 ofponding, condition of vegeta-ion. etc.): PRIVY: Al (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 vezetation_. etc.;.: Titl<� Tn CTP/•+inn T=nri�s ����i�nnn o a Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSIIEN TS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION E©R'xI PART C SYSTEM INFORMATION(continued) Property Address: Qb /�/��i G �/�v'G— �rS Owner• &S4 Date of Inspection: JP o' SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference Ianarks or benchmarks. Locate all wells «,ithin 100 feet.Locate-,,,,here public water supply enters the building. oti T 6 1 F71 er s t — F•� 4d.- �� 1 y L,- 67 )91 �n Page 11 of 11 OFFICIAL.. INSPECTION FORM-NOT FOR VOLUNTARY ASSESS'11ENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR_j.I PART C SYSTEM nTFOR-MIATION(continued) Property address: ` 04 6 lifw?lC Gas � /Y!• /�iJ ct�-6�a Owner: �eS Date of Inspection: SITE EW Slope cZ10 Surface water 19A<IL Check cellar (a.�f x Shallow wells /r/b i��� L4°1 Estimated depth to ground water 9 feet Coo*'_ 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(abuttin g g property/observation hole within 150 feet of SAS) Checked with local Board of Health-exTlain: Checked with local excavators;installers-(attach documentation) Accessed tiSGS database-explain: You must cWc ' how you established the high gro�n� atf r levation: 60 0- L—e-ki4 7`te Id Ze/ow �a ole _ �r � �ti 7�io••, /t S. - S /-r /7Q0,4_116� r G.� T.it7c � Tncnontinn �nrni �n v�nnn _ li THE COMMONWEALTH OF MASSACHUSETTS BOARD F LTH Appliratiaatt for Diaposal Works Tonstrudion j1prual Application is hereby made for a Permit to Construct o or Repair ( ) an.Individual Sewage Disposal Syst t. z�e 4, ]® on-Add or Lot No. - i{- — —^- .—r —_ — —__------- — --- --- ----•-------------•-------- W Address a - ----------------4 - ------------- W Installer Address UType of BuildingSize Lot---------------------------Sq. feet Dwellingl No. of Bedrooms----------------------.------------:-----.Expansion Attic ( ) Garbage Grinder ( ) _--- No of persons-__-•-_--•-------••-__._-_-- Showers ( ) Cafeteria { ) p., Other—Type of Building -------------------_- -- . — Qa' Other fixtures _. .__.. -------•-------------------------------•-------------------------------------------- - Design Flow---------------- ----- ----gallons per person per day. Total daily flow--------.-�_ ---_--__--gallons. W - _ P . P P Y Y WSeptic Tank/-Liquid capacity gallons Length---------_----- Width-___ __________ Diameter__---._-_.:__-_ Depth..._.., x Disposal Leh—No__________________-- Width__ Total Length----- _ Total leaching area_' sq. � Seepage Pit No_____________________ Diameter.------.:-----__-_-- Depth below inlet------_--�_-�-- Total leaching area--------°-------_.sq. it. z Other Distribution box ( ) - . Dosing tank ( ) a Percolation Test Results - - Performed by---------------------------------- ------------------------------ Date-------------------------------------- HTest Pit No. 1................minutes per inch Depth of Test Pit------------------- Depth to ground water............________.__. (� Test Pit No. 2----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water________________________ ----•=----------------------------------------------------------------------•=---------_ ------------------->------------------------------- 0 Description of Soil-------------------------------------- x U --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------............w v 1\ature of Repairs or Alterations—Answer when applicable._-_---__--••_••-__------------ •------------------------------------------------------•-------•------------------•---------------------------------------------------------------------------------------------------------------- Agreement: The undersigned agrees to. install the aforedesc 'bed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Co —The undersi urther agrees not to:place the system in operation until a Certificate of Compliance has sued by thejb. ApplicationApproved BY---------------------------------------------• ---------------------------------------- ---------------- --ate-------------- Date Application Disapproved for the following reasons_.............-_--------------------------------------------__:_-- -------------- -------- ------------- --------------------------------------------------------------------------------------------------------------- ------ --------------------------•--- IT ate ------ Issued_ �� Permit No----------------------------- - - - THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEAL H .�.............OF........ es .. ................. (In iliratp Of lamphima TH I T ERT Y at ndividual Sewage Disposal System constructed (147 Repaired ( ) by- - - - - --------------- ---------- ----------- ----- - -- _- Install ------------------- has .been installed in.accordance with the provisions of Article XI of The State Sanitary Code as described:in the application for Disposal Works Construction Permit No:_••-_-•--:- '- °_______________ dated___- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE.THAT THE SYSTEM! WILL FUNCTION SATISFACTORY. DATE----------------- r. _ A _oT------------------------------)q. feet DwellingNo. of Bedrooms..............* oj'ze................----Expansion Attic j Garbage Grinder ( )- jK 414 Other—Type of Building ---------------------------- No. of persons---------------------------- Showers Cafeteria Other fixtures Design Flow-------------------------- --------------- ----------------- -------- -_-----gallons per person per day. Total daily flow_.___.___------ ----------------------gallor.s. Septic Tank_Liquid capacity, Ions Length_.._.__...__._...... Width Diameter______-________---- Kl— ----- Depth___.._ Disposal Tqmch—No No.---------- ----- Total leaching area . - Width--- Total Length------ 0 ot Seepage Pit No--------------------- Diameter-------_:_-- th below irilet------------;.L— q. ------ Total leaching area----- sq. .z Other Distribution box Dosing tank Percolation Test Results Performed by--------------------------------- ------------------------------- Date------------------------------ Test Pit No. I----------------minutesperinch Depth of Test Pit__--..____________-_ Depth to ground water_.._---____--_-.____.-_. Test Pit No. 2---------------minutes per inch Depth of Test PiL:------------------ Depth to ground water__-__-___-__--___---__-- -------=--------------------------------------­------------------------------------ ---------------------------------------------- 0 Description of Soil---_-----------------------------------------------I U -----------------------*-..--,--------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------- Nature of Repairs or Alterations—Answer when applicable-------------------------------------------------------------------------------- -------------- ------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedes 'bed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Co —The undersi urther agrees not to place the system in operation until a Certificate of Compliance has sued by the b Application Approved By------------------------------------------------- --------—--------—---------------—----— Date —-—--------------------------------- Date Application Disapproved for the following reasons______________-__---______-_ ------- --------------------------------------------------------------------I-------------------- ------------------------------------------------------------- ------------ - ------------------- ------- ate -- PermitNo----------------------------------------------------- Issue(i- -—-- ------ -- ---- --- ----------------- a THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEAL H .........OF........ . ................. Tntifirdr if :1.1implim" TH4S I. TQIiCERT, �a�7/ ndi-vidual Sewage Disposal System const ructed Repaired by------ ..............................-------- ----------------------------------------------------------------------- Inst 11 at--- ---0�a .....�Z_7------ A mi,---:;��I&_ v-------4_1�,4--- -------------------------------- has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described:in the application for Disposal Works Construction Permit No........__ --------------- -1-7---Y- dated----/_,7__A/-------------------------- THE ISSUANCE.OF THIS CERTIFICATE SMALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE--------------------------- ------------------------------ Inspector-------- ----------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF, HEALTH . ........... ......OF........ No------ Permission is hereby granted______ ._ __ _ -- to Coristr ct . . . --------------------- `'or Rep an Individual Sewagepis at ------------------ ."for St3ee as shown on the application.farDisposal Works Construction Permit No__________________-_ Dated. -------------—-—-----—-------------------------- DATE--------------- Board;of Health --------------------------------------------------------- FORM 1255 Ho BBS & WARREN. INC.. PUBLISHERS J- 41 --- ------- No...LI-fX-•-------• r FEx lz' ...................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .OF:.... . ........ ........ . . W,,? Applilration for Diivaoal Workii C omitrurtio n Pumit Application is hereby made for a Permit to Construct or.Repair ( ) an Individual Sewage Disposal •S1t44-1 : L ion.Add s or Lot No. 1�........ - -•-----------•---•------------------- -------•-•---------•-------••----••-------------••----------•---•-..._--•-•••••-••---------------- Or ....................................••--•--.Address Installer Address Q Type of Buildin e ` Size Lot-________-_•________________Sq. feet U DwellingYNo. of Bedrooms----___________/__`r___.__.__._.__._...__..__Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons.__-______-.___-___--_-•-_-_ Showers ( ) — Cafeteria ( ) Other fixtures _. ____ ---------------------------------•-•••••--------•-----••---•••-•••••-•--•------ W Design. Flow..................................• •.-___gallons per person per day. Total daily flow_______•_••.-_- __.__.__•1---_________-.___gallons. WSeptic Tank/—Liquid capacity gallons Length................ Width.-_ _-.. ..... Diameter................ Depth.-_.__ -.�f x Disposal Leh—No..................... Width. Total Length----- Total'leaching area...7. sq. f Seepage Pit No--------------------- Diameter.................... epth below inlet.......... Total leaching area________'_______--sq. ft. z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by-------------------------------------- ................................ Date---------------------------------------- a Test Pit No. 1...........:....minutes per inch Depth of Test Pit.................... Depth to ground water__-___,____-_________--- L� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water_____________________-_. --------------------------------•-•----------'----------------------•-- -----------•--------- ODescription of Soil........................................................................................................................................................................ x U W ---------------------------------------------------------------------------------------•-------------------------------------------------------------------------------------------------------------- V Nature of Repairs or Alterations—Answer when applicable.__________________________________________________•---•._._--_-----_.-.-_-.__.______-_--------. --------------------------------------------------------------------------------•---------------------------•--------------- ------------------------•--------........_..__....----------•-•----•••---- Agreement: The undersigned agrees to install the aforedesc •bed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Co —The undersig urther agrees not to place the system in operation until a Certificate of Compliance has be sued by the/b f e G Signed-- • ------------ --------- -•-• --- ---- •-- - Date ApplicationApproved By................................................. -• ............................................ Date Application Disapproved for the following reasons---------------••----••-...-•--•---•••-••••--•-••-....•-•---•------------------••----•••----••-••--•---------_... ------------------------------------•---------------------- -----------------------------------------•--- n ate Permit No........................................................ Issued:- a!-- ... . . /i'at No..-r.- • ----•-• Fiz$.,.,Z....................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH , sa _.........OF... .. ------------------------------ Appliration for Disposal, Murk, Tou' litrurtiou Prrmit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal f v 'Syst at: a ® Lo ion-Addr as or Lot No. i }O br Address W ' nsta er' Address UType of Building Size Lot _--•-_•_________________Sq. feet Dwelling No. of Bedrooms_________________ _________________________Expansion Attic ( ) Garbage Grinder ( ) 04 Other—,Type of Building ....:....................... No. of persons............................ Showers ( ) — Cafeteria ( ) Pa Other fixtures ...................................................... W Design Flow...........................s - _._gallons per person per day. Total daily flow..............•_ -_� _-_-_.-----_gallons. WSe?tic Tank/--Liquid capacity/_a$dgallons /L....... Total Length..----- - -•----- Total leaching area---- _sq. ft. Seepage Pit No--_---------------- Diameter.................... Depth below inlet...._....______..... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( -) Percolation Test Results Performed by........................................................................... Date-------------------------------------... a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water_-_.___-_________--_..-- (� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.................... ----------------------------------•-------------.._..---.....---•--•--•••............---------•-----......................................................... 0 Description of Soil........................................................................................................................................................................ W UNature of Repairs or Alterations—Answer when applicable-------------------------------------------------------------------...___-__._.-____._-__-----. ---- ---------------•--------•-•--•----•--••--••-•--•--•-••-----•--•-•----••----•------------------------------------------------------------------------------------------------------------------ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Co —The undersig 44 further agrees not to place the system in operation until a Certificate of Compliance has bee sued by the boar of '. . Signed__ ' b = " Date' ApplicationApproved By................................................ " ------• . -----....------------------------------- Date Application Disapproved for the following reasons: = = •------------------------------------------------------ .................... --------•----•---------------------------------------------------------------------------- -----•---•-•-•-----------------------------------------------------------------..................... 'Date PermitNo......................................................... 'Issued...------------------•---------------------------------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH , .............OF......... t ss� ; 40--- Tatif irate of fuutpliana y TH.S j Y, iat 1� ndividual Sewage Disposal System constructed (tor Repaired ( ) b ` T �T ------ ---------------- Installer 6164 has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described:in the application for Disposal Works Construction Permit No.............I. Al............._. dated....1.7.. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector-----------------------------------'.................................................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH l .............. ; . .......OF....... � , g,4• ..................• J No......�• g ....... FEE ............... �- Permission is hereby granted---------- -- ........... ,:--------•••--- •-----•---------=•-•-------••-----------•••-----------------••----------. to Constru t , j"°or Rep 1 ( ) an Individual Sewage Dispa] S s m _ at No. oaf, = � .. .. `r "" ; -- ---- Street / as shown on the application for Disposal Works Construction Permit No_____________________ Dated... r/__ 4._._...._ --------------------------- ...................... -------------- .............................. Board,of.Health DATE................................................................................. r IL FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS �"" '03 ""' jR' "x � � • z 4 1 1 TOWN OF BARNSTABLE UNDERGROUND FUEL AND CHEMICAL STORAGE SYSTEMSV4 ASSESSORS MAP NO.��•1 �� PARCEL NO. ADDRESS! IVQ(, , �lLc�rrv. VILLAGE: 6��,�, Ai! s 9� tdAME CONTACT PERSON PHONE NUMBER J"JO LOCATION OF TANKS. CAPACITY: TYPE OF' FUEL AGE: TYPE: LEAK OR CHEMICAL: DETECTION SYSTEM' �.S [n 7f 9 ljfl7lLq— Ig rAh DATE OF PURCHASE OF EACH: 1. 3. 4. 5. DATE OF FIRE DEPARTMENT PERMIT: f ( ul TESTING CERTIFICATION SUBMITTED: PASSED DID NOT PASS cut cox Ax �PA k6 r 16, ftA wu. 4 4 kkcol,t &JLV,,�rn ao PLEASE PROVIDE A SKETCH SHOWING THE LOCATION OF TANKS ON THE BACK OF THIS CARD. RD �l u'6-- Dope