HomeMy WebLinkAbout0221 SHOOTFLYING HILL RD - Health 221 SHOOTFLX1Nr HILL ROAD`;
.. A= 214 018
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I UwI1 OI BiiCIlStill)lC 1' 11
Department of Ilcallh,Safely, and Environmental Services
Public I-Ieallll Division Dale
t� $ 367 Main Street,I lynnnis MA 02601
• uAarrsrentx :
MASS
t639. Dale Scheduled
foµn I lme Fee I'd.
Soil Sclitabililp Assessment for' Sewage Disposal
I'erfunncd Ily: l rr� Wilncsted By: - r+��t�wvr,>;j\t
�� 'IZAL I1VI OI
{� LOCATION & GLNL ZIYIM-O
r Location Address
✓' Lo*- sr� Owner's Name� Yry�y� -t•r�y�, �,p�
Assessor's klap/l'arccl: j)Ad(lfc
Engineer's Name STEPHEN J. DOYLE ABB
42 Canterbur ®�
NF-W CONSTRUCTION REPAIR I
�relepnmte n East Falmouthh MA, � 62536
1 e ep one:. 508 540-9g1t
Land Use �ti�A+SK.r \1.10o i� Slopes("".) fir-110--* I y' Surface Stones
I)islnnccs Bonn: Open Witter Body _11 Possible Wel Area 15 V n Drinking Water Wcll) S l� fl
i
Drainage Wny 7 b 11 Properly Line 11 Other (I
SS MPITCI I: (Slice(name,dimcosious of lot,exact local ions of lest holes&pert tests,locale,vcllnnds in proximity to holes)
*
Parent material(geologic) Q,"u" Depth to lledrock �Jg�
Deplll to Groundwater: Standing Water in l inlc: Weeping from I'it 1�nce
Estimated Seasonal Iligh Gromtdwaler fit, 3i. o
P TERMINATION rOR.SLASONAL III 111.1VAI'I�Ii.1ABLL
Mcillod 0sed: \ o,qs���. `�mu_
Depth Observed standing in obs.hole: in. Depth to soil mollies:
Depth to weeping from side of obs.hole: in. Groundwater Adjustment R,
_ Index Well 1! _ Rendb,R Dale: _ — Index Well level __ — Adi.factor —_ Adj.Groundwater Level
PCRCOLATION41,8 1
Observation
I role rl ( Time at 9"
Depth of Pere 3o a 7o t` Time at 6"
Start Prc-soak'rime a \\:\\p W.-', lime(9"-6")
Elul l'rc-soak 1\'-3 tom` p --Lot Gehl' %A X&
Rate Min./Inch
Site Suitability Asscssmcol: Site Passed Site Failed: Addilional lesliug Needed(YIN)
Original: Public Ilealth Division Observation I tole Daln To Ile Co.nlple(ed on Ilnclt j
Copy: Appiicnnl
. 1)I!,I!,I' U13S1!,ItV�'1'I'ION L:LOG IIoIc 1E �
Ueplll Bolo Soil I[ofizon WIT exture Soil Color Soil Cider
Surlirce(in.) ((IShn) (f,'lunsclll) hlullling (Slnrchnc,Sloncs,Ilouldcres..
n/
(` t
llERT OBSERVATION IIOLL LOG Ilu1c 11 Z
Depth fiom Soil I lurizun Soil Texture Soil Color Soil 0111cr
Surface(in.) (IISDA) (A'lunscll) hlullliog (Sfruclurc,Stones,Iluulderes.
-- — — S�OiL4�51cncv.;'o Gr twcl)
O-"A
------ — — — — ----- _ \.uo%S
It
DEUT OBSIPAOIATION I10LL LOG [Illlc I'1!
I)cplh Poll) Soil Ilorizoo Soil Tcs.lurc Soil Color Soil Olhcr
Surfirc:e(in.) (USDA) Alansell hlnlllin
( ) Shuclurc Sloncs Ilr ul •c ( r dues.
--- — nIIIS1Sl1Sx
I)IPLI). OB814AVATION HOLE LOG hole#
I)cplh Bunt Soil I lorizon Sail Texture Soil Color Sail C)Ihcr
Surface(in.) (IISDA) (t`hmsell) Nlullling (Slruclorc,Sloncs,Ilouldcres.
-- - - •Ir ISI�LILY.1��!I1lY�1)
— -- - ----- ---- ----- -----...........
i
h o0
—n1e Nfil1Li
Above 500 year flood boundary No -- Yes
\vilhin 500 year boundary No Yes _
Wlllrtn 100 year flood boundary No Yes--
I)ci)tl> (jLL)).hjLaj1 cc lLjj)I!t:_I� l:.Y"s Nl_lilcri;il
Does at least four feel of naturally occurring pervious nullerial exist in all areas ohscrvc(I Ihro(Ighont the
area proposed for the soil absorption syslenl'?
I f not, what is file (leptll or naturally occurring pervious nlalerial?
I cerlify Ill-all oil _ \AA (dale) I have
— passed file soil e valuator camin atioll approved
) )roved by
fi
le of Lnvlronn)cnlal Prolcction and 111a1 the above I a sls was )crfornlc(I y mc consistent with .
(he reciuired Iraining, expertise arl(I experience described in 310 CMK 15.017.
Signature — — --- - Daic
y�
I COMMONWEALTH OF MASSACHUSETTS g
EXECUTIVE OFFICE OF ENVIRONMENTAL AFF ro
DEPARTMENT OF ENVIRONMENTAL PRO TIN
rf ONE WINTER STREET, BOSTON, MA 02108 617-292-550 ���
2 s
1
WILLIAM F.WELD (�
Governor (j 'IRLD•� O?iE
cretarv.
ARGEO PAUL CELLUCCI ti D B STRUHS
Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner
PART A
CERTIFICATION
221 Shootflying`Hill Rd. Kurt Lariviere
Property Address: Address of Owner:
Date of Inspection: `I $� (If different)
Name of Inspector: WIT Robinson Sr
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: Wm E Robinson Septic Servi
Mailing Address: PO Box 1 089, CPnt-Prvi 1 1 a _ Mr 02632
Telephone NumberY 5 0 8, 7 7 5_A 7 7 6
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 as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewa a disposal systems. The system:
' asses
— Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
_ Fails
Inspector's Signature: 4 i,I; ✓ Date: 9
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (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 Department of Environmental Protection. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
4
' INSPECTION SUMMARY: Check A, B, C, or D:
i
A] SYSTEM PASSES:
AI have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
COMMENTS:
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.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not.
_ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
tj Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
I
as approved by the Board of Health.
(revised 04/7S/97) page 1 09 10
DEP on the World Wide Web: http1twww.mapnet.state.ma.usldep
Printed on Recycled Paper
I .
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
` PART A
CERTIFICATION (continued)
Property Address. Sh Y g
221` ootfl in Hill Rd. Centerville
Owner: Lar iv i e r e
Date of Inspection:
B). YSTEM CONDITIONALLY PASSES (continued).
f
_ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the
Board of Health). Describe observations:
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four 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
C) FURT R EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
` onditions exist which require.further evaluation by the Board of.Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
j 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) S STEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
E SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
NVIRONMENT:
_ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or
tributary to a surface water supply.
_ The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis 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. Method used to determine distance (approximation not valid).
3) THEIR
p
(revised 04/25/97) Fag. 2 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 221 Shootflying Hill Rd., Centerville
Owner: Lariviere
Date of Inspection:
Di SYSTEM FAILS:
You t indicate ei;!,er "Yes" or "No" as to each of the following:
have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
f r this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
th failure.
Yes No
Backup of sewage into facility or system component due to an 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 1/2 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a 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 I 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E]ILAR E SYSTEM FAILS:
You m st indicate either "Yes" or "No" as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
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)
The ow r or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
require ents of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 04/25/97) Page 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
t
Property Address: 221 Shootflying Hill Rd., Centerville
Owner: Larivier
Date of Inspection: -9
Check if the following have been done: You must indicate either "Yes" or"No" as to each of the following:
Yes No
_ Pumping information was provided by the owner, occupant, or Board of Health.
_ None of the system components have been pumped for at least two weeks and the system has been receiving normal
flow rates during that period. Large volumes of water have not been introduced into the system recently or
as part of this inspection.
As built plans have been obtained and examined Note if they are not available with N/A.
The facility or dwelling was inspected for signs of sewage back-up.
_ The system does not receive non-sanitary or industrial waste flow.
_ The site was inspected for signs of breakout.
_ All.system components, excluding the Soil Absorption System, have been located on the site.
The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of
baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal System.
_ Existing information. Ex. Plan at B.O.H.
_ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) [15.302(3)(b)]
(revised 04/25/97) Page 4 of 10
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 221 Shootf lying Hill :Rd., Centerville
Owner: Lariviere
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow: O g.p.d./bedroom for S.A.S.
Number of bedrooms:3
Number of current residents: 3
Garbage grinder (yes or no):,At.a
Laundry connected to system (yes or no):
Seasonal use (yes or no): 15t 6 TIlOS . Z�98 67, OOOg
Water meter readings, if available (last two (2)year usage (gpd):
Sump Pump (yes or no): L ' Uuug
1996 108, 000g
Last date of occupancy:— 9
COMMERCIAL/INDUSTRIAL:
Type o establishment:
Des gn 'ow: gallons/day
Grease t p present: (yes or no)_
InclLstrlal Waste Holding Tank present: (yes or no)_
Non-sanit ry waste discharged to the Title 5 system: (yes or no)_
Water m er readings, if available:
Last dal of occupancy:
OTH . (Describe)
Last da of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and so rce of information:
17
System pumpegKas part of inspection: (yes or no)A.O
If yes, volume pumped: t allons
Reason for pumping:
TYPE OSCYSTEM
� eptic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
I/A Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information:
Sewage odors detected when arriving at the site: (yes or no)k®
(revised 04/25/97) Page 5 of 10
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 221 Sh,00tflying Hill' Rd:, Centerville
Owner: Larivier
Date of Inspection:
BUILDING EWER:
(Locate on sit plan)
Depth below g de:
Material of con ruction: cast iron _40 PVC_other (explain)
Distance q(con
ate water supply well or suction line
Diameter
Commention of joints, venting, evidence of leakage, etc.)
SEPTIC TANK:_
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal Fiberglas _Polyethylene _other(explain)
"#,- i
If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No),
L ti
Dimensions: C 4 ` �� 6
Sludge depth:{3_ s-
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: y—S, I ,
Distance from top of scum to top of outlet tee or baffle: '(�
Distance from bottom of scum to bottom of outlet tee or baffle: d
How dimensions were determined: d )Oti- 1 e H-X,
Comments:
(recommendation for pumping, condition o inlet and outlet tees or bps, depth of liquid jevel in relation to outlet invert,.,Wuctural
integrity, evidence of leakage, etc.) O A/ J d J" c` J X2 0 br
GREAS TRAP:
(locate o site plan)
Depth belo grade:
Material of onstruction: _concrete _metal Fiberglass _Polyethylene —other(explain)
Dimensions:
Scum thickn ss:
Distance fro top of scum to top of outlet tee or baffle:
Distance fro bottom of scum to bottom of outlet tee or baffle:
Date of last umping:
Comments:
(recommendat on for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evide ce of leakage, etc.)
(revised 04/25/97) Page 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 221 Shootf lying Hill Rd., : Centervi_lle
Owner: Lariviere
Date of Inspection:
TIG T OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection)
(locate on site plan)
Depth low grade:
Material f construction: _concrete _metal _Fiberglass _Polyethylene _other(explain)
Dimensi ns:
Capacity: gallons
Design f w: gallons/day
Alarm I el: Alarm in working order_ Yes; _ No
Date of revious pumping:
Comm nts:
(co ndi on of inlet tee, condition of alarm and float switches, etc.)
DIS:RIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
PUMP C AMBER:_
(locate o site plan)
Pumps in orking order: (Yes or No)
Alarms in working order (Yes or No)
Commen
(note co dition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 64/25/97)
Page 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 221 Shootflying Hill Rd., , Centerville
Owner: Lar iv iere
Date of Inspection: /l-- G q T
SOIL ABSORPTION SYSTEM (SAS):v/
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type:
leaching pits, number:-
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, lev I of po di�n/Q� condition of vegetation, etc.)IS
a•
CESSP OLS: _
(locate site plan)
Number a d configuration:
Depth-top f liquid to inlet invert:
Depth of so ids layer:
Depth of sc m layer.
Dimensions f cesspool:
Materials of onstruction:
Indication of roundwater:
infl w (cesspool must be pumped as part of inspection)
Comments:
(note Condit' n of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:_
(locate on site Ian)
Materials of con ruction: Dimensions:
Depth of solids•
Comments:
(note condition of oil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 04/25/97.) Page 8 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 221 Shootflying Hill Rd.; Centerville
Owner: Lariviete
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
t t),
a
(J
41
a
a
(revised 04/25/97) Page 9 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 221 Shootflying Hill- Rd., Centerville
Owner: Lariviere
Date of Inspection: �� G
JX
Depth to Groundwater Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
1/ Observation of Site (Abutting property, observation hole, basement sump etc.)
Determine it from local conditions
Check with I r f health
it Iota Board o ea
Check FEMA Maps
Check pumping records
Check local excavators, installers
Use USGS Data
Describe in your own words how you established the High Groundwater Elevation. Must be completed)
•
(revised 04/25/97) Page 10 of 10
F_
.. TOWN OF BARNSTABLE
LOCATION Sko-d` ►GI SEWAGE #
VILLAGE °�LkgA a 41L ASSESSOR'S MAP & LOT
INSTALLER'S NAVE & PHONE NO.
SEPTIC TANK CAPACITY 1-6 D
LEACIiING FACILITY:(type) � por) (size)
NO. OF BEDROOMS Sj _PRIVATE WELL OR PUBLIC WATER
BUILDER OIt OWNER_<, V� -
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
Z g
VAR •.���*�-E�:Yes"`�.�.,`" No .��
��. A��
,� D�
"'�( y
'� •"
`,� ..
Q
_�
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No..� .. .7 FRs......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD -OF HEALTH
..................OF:::.......�M. fA�
ApplirFa#ion for Disposal, works Tonstrnr#ion Frrutit
Application is hereby made for a Permit to Construct (t,<or Repair ( ) an Individual Sewage Disposal
System at:
------------------ ...............................................
.... _.....-•--•---•-----------.............----
ocation•Add ess or Lot No.
l �" �R_... 1 ..1. ! .....................
e � Address
�
e o •
a .........�.........�....�.. ...... ���..v ..................................................................................................
staller Address
Type.of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms............. -__--Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ............................ No. of persons------- ................ Showers ( ) Cafeteria ( )
Q' Other fixtures ................
Design Flow...:............................ .;S. allons per person per day. Total daily flow----,..Z ..........
-................gallons.
p .gallons Length------- ..... `�lidth-____-f-------- Diameter................ Depth................
W Septic Tank—Liquid*ca ac'
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area-----...............sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by........................................................................... Date.......................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
�T4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
9 -------------•------------ -••-------------------••-••••--•----...------.........-- •.---- ---....------------•--.. -------• -----._...-•---•-----•--
ODescription of Soil.................AS.:A�((....Q62-.^................•-•-•-----•-••---•••----••----•••-•--•--------...........-•-•---•---......--•-----•--------•--•-
x
W
U .......
-.---
-_6---------
---•--------
------------
--------------------
--------------
•-----------------------------------------
---------
---------------
...__•----------------
-------------------
-----------
'
....................................................................................................................
/J........
0 Nature of Repairs or Alterations—Answer when applicable-------------------------------------------_________________________ __________________________
---------------------------------•-------------•--•---•----•---•-••-•---•--•-------.................------------------------------•••--•------...._---•-------••-••••---•••-----------•----....••.......
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITLEE 5 of the State Sanitary Code T e undersigned rt, r agrees not to place the system in
operation until a Certificate of Compliance has been i ed e bo eal
loo
Signed -----• �f� cf �
Date
Application Approved By--------------- ••• .....-- a•--------------------- --------- ............
Date
Application Disapproved for the following reasons:................................................................................................................
--......-•-•---------•-------•--•----•-•--•-•---......--•-•----•----•---•---•------•-•-----•..............--------------•------------------------•-----•---•...---•-------------•----------•-•--...------
e Date
PermitNo...._..t�.- .1 ........................ Issued......................................... ...........
Date
44
THE COMMONWEALTH OF MASSACHUSETTS
Application is hereby made for a Permit to Construct (_�,J"or Repair an Individual Sewage Disposal
System at:
^^
t=
(Aocation--Address or Lot No.
Au�"�
� ��"�r ' � Address
ype c� S�c feet �
' �
Grinder ( )
04 Other—Type of Building ............................ No. nf persons-------�e---------------- Showers ( ) -- Cafeteria ( )
04 Other fixtures ---'..-..--_-----__.-.------...---.---_---.---'--------_-_-''--_------
` ���
Design Flow............................... per person day. Total daily flow,-����----'_-_-__-' .
Septic Tank—Liquid Length Diamcter------ Dcoth................
Trench--No .................... Width.................... Total Total ft.
Seepage Pit No..................... Diameter-._---' Depth below inlet.................... Total area..................sq. f t. �
z Other Distribution box ( ) I)ooins �uo� ( ) �
- �
'- Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. l................minutes per inch Depth of Test Pit.................... Depth to ground water--.__—_-
�zq Test Pb No per inch Depth of Test Pit.................... Depth to ground water........................
0 Description of ---
------'--'--''----------------'-''-------'--------'----'------------'--'----'-'-'---'------
z ------------------.-------_--.-_--_-_----'_-------.-_-_--'--'--_--------_.-----__
U Nature of Repairs or Alterations—Answer when uoo1icuhle----_-.-------_-.-_------.--.-------.-. �
----------'---------`--`--`---'`-----`---------``------'-------`-''-'---`'----'---`------
''"'_--_-.
The undersigned agrees to install the uforedescri6ed Individual Sewage Disposal System in accordance with
the provisions of T I T I-E 5 of the State Sanitary Code The dersignedf6r-d-Ir agrees not to place the system in
operation until a Certificate of Compliance has been i ed eb or cal
_-----'-__.__-__-__-_-.-_-_----_.-___--__---''--_-_-_'-_-'_-----'-_'_----.-__'----__-
Date
Permit
Date
THE COMMONWEALTH op wAssAc*ussrrs
BOARD OF HEALTH
...........
............OF........./�3 �^�a� -----------.
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Ir��ufirat�
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed 6<) or Repaired ( l
by....................................................................................................................................................................................................
a��
nt______.,(.^z_�r./�__._ �� 7- ___�^�__r___ ------Y�. __,,� _._____
has been installed in accordance with the or�iuiooy of TIT 5of The State Sanitary Code as described in the
application for Disposal Works Construction Permit BTn......./2.l.......... ------- dutcd-'---'-.------.---..
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.---�e-? ..............��'���.................................. Ioopectd��-'���-'d����.�����. 'l
/~ - ''77-'--'------_________
T*scoMMomwsALr* OFmAssAc*uScrrs
BOARD OF HEALTH
/y.
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-_- - ... ___=�__--
Peroz�»ioo is 6er�n' -----������...-.... --------L�'-.---.--.-.................................................................
to Construct C><) or Repair ( ) an Individual Sewage Disposal Sy t
�--�'
'--'--------------------'--
Board of Health �
DATE..............................................................................
ponM /zss x0000wWARREN. INC., puous*sns
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L I`vim'
L-"( z0, 1989
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