HomeMy WebLinkAbout0307 WOODSIDE ROAD - Health 36-1 Woodlside, 900.4
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No. 4210 1/3 BLU
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ESSELTE
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TOWN OF BARNSTABLE
LOCATION "30-7 SEWAGE # q7 t.
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VILLAGE c°►'2y� �c-�� ASSESSOR'S MAP& LOT
INSTALLER'S NAME&PHONE NO � '
SEPTIC TANK CAPAC=
LEACHING FACIL=: (type)_i�� 1(x-��`'�— :-ift (size) Z 1` t
NO.OF BEDROOMS 15
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BUILDER OR OWNER
PERMTTDATE: �3-:-�COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bcaom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
I. Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
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TOWN OF BARNSTABLE
LOCATION.. `3o 1; Orty-e. SEWAGE # L
VILLAGE> tA6��eL ASSESSOR'S MAP& LOT—IL 2 �.�,7
INSTALLER'S NAME&PHONE NO,--iZ0015g �
SEPTIC TANK CAPACITY �'zx `�'t��.— lL ,a Y�`�c•J
LEACHING FACILITY: (type) (size) y Z 2C i
NO.OF BEDROOMS
BUILDER OR.OWNER —CJ`��S c
PERMITDATE: I5r- a L9 7 COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Be.,om of Leaching Facility Feet
Private Water.Supply Well and Leaching Facility (If any wells exist
on site or:within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
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No. / `~ Fee--L /
Entered in computer:
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THE COMMONWEALTH OF MASSACHUSETTS
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
Zipphratton for M,5pogar *p5tem Con5tructfon Vertu
Application for a Permit to Construct( )Repair( /upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No.367 Owner's Name,Address and Tel.No.
l�v 3�. �b�
Assessor's Map/Parcel f
j 1<0'�1,S
a_d
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
2 � 6
Type of Building: �� /
Dwelling No.of Bedrooms '7 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow `7� gallons per day. Calculated daily flow 6�~7 gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank —S�r-Y S%r� \015b Type of S.A.S. -�` — e` i 1►-��£LL�rc
Description of Soil iM 5 0
Nature of Repairs or Alteratioqns(Answer when applicable) �S�w
✓-�-� Cti�V1l �.'w�i�—(r��QS ,W ` tlWS � ..� ���� �I.TtQ�,�
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this B d of Health. 7
Signed' Date
Application Approved by Date
Application Disapproved for the ollowing reasons
Permit No. Date Issued
i., . �•e .r."Gr .r � ��� '. }� ..... ...•ti... 1.yh`.n.+._ .s . .. r-W _ '�ei , .^q,F.
1 - - _
No. 7 ' � '. Fee
` THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes
PUBLIC HEALTH DIVISION - TOWN 0 BARNSTABLES MASSACHUSETTS
3pprication for �Diqaal *pgtem Con!6truction Permit
Application for a Permit to Construct( )Repair( Apgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No.307 (,k"b5t Q f�9 6 v-f. Owner's Name,Address and Tel.No.
Assessor's Map/Parcel
11j.3�-�st�b�., Xo'r'TN'S
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Installer,'s Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 1
I.
Type of Building:
C
Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( Cafeteria( )
Other Fixtures
Design Flow gallon',per day. Calculated daily flow &:)I)"7`- gallons.
Plan Date Number of sheets J_i.,I Revision Date
Title F M ,l
Size of Septic Tank of S A.S, ^�h L
Description of Soil tM ' S « o _
Nature of Repairs or Alterations(Answer when applicable)
r�,Z 6 �x1� �' Oar-�S aY�e S i �� .t�c�r�✓
- --�-
Date last h"spected:
Ag a ment: I
I
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this Bo d of Health.
Signed Date
Application Approved by - Date
Application Disapproved for the 91lowing reasons
Permit No. Date Issued
---------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY, that the On_st wage Disposal System Constructed( )Repaired ( ,)-Upgraded(�
Abandoned( )by 0 1 _
at 2 1 x�DS'� �DVr has been constructed,in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No.�.L dated
Installer Designer
The issuance of this permit shall not be construed as a guarantee that the system wiell.function as designed.
Date lip d �"' ( � Inspector
------------------------ - --------------
No. Feet!
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
Mizpogaf *p.5tem Construction Permit
Permission is hereby granted to Construct( )Repair(L.-pgrade( )Abandon( ) I I .
System located at —?d 7 We6D5,0c_. CY'(k)c_
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided: Construction must be completed within three years of the date of this permit.
Date: S" SS 77 Approved by 141
NOTICE: This Form is to be used for the Repair of Vailed
Septic Systems Only
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL'.
WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS)
hereby certify that the application for disposal'works
construction permit signed by me dated concerning the
property located at 30) meets,all of the
r
following criteria:
• There are no wetlands within 300 feet of the proposed septic system
• There are no private wells within 150 feet of the proposed septic system
• The observed groundwater table is 14 feet or greater below the bottom of the leaching facility
• There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
SIG DATE: S '`?'7
-LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE N"Ek
[Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
-----------------------
J-L-----LL
--- Fee------ -------------
BOARD OF HEALTH if
TOWN OF BARNSTABLE
�lApplicat ion-for lVerr Conotruct ion ermit
i
Application is hereby made for a permit to Construct ( ), Alter ( ), or Repair (r l n individual Well at:
Location — Address Assessors Map and Parcel
Owner Address
��/
-------- ----------------------------------------------------------------------------------
Installer — Driller Address
Type of Building
Dwelling-- .� �
Other - Type of Building--=---------_._.____ No. of Persons--.-----.-------- _--- -__-
Type of Well Capacity------------ --_-_—__--
Purpose of Well-- A It -----_--— —_
Agreement:
The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The
Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to
place the well in operation until a Certificate .of Compliance has been issued by the Board of Health,
Signed � � --e——_— o _1�L1 d
Application Approved By
j ate
Application Disapproved for the following reaso(Z
-- � — -- -- _—_--__--._ _ _------- date —�---
- ----- ----
Permit No. ---� Issued---- -`''`-�--_-----—__—_ _-_-_
date
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate ®f Compliance
THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired (4-y'
by__-- — 1 —--- ___- -----------------------------------
-- - ------ _______----
Installer
q
has been installed in accordance with the provisions of the Town of Barnstable Board of Healt vate Well Protection
Regulation as described in the application for Well Construction Permit No. ---- ated—--------------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE--- --- -- - -- Inspector---- —------- ---
No.
BOARD OF HEALTH
TOWN OF BARNSTABLE
� oz � Cuat�ton:;�or�eCi �on�truct�on ermit
Application is hereby made for a permit to Construct ( ), Alter,(_ ), or Repair (V)an individual Well at:
.Y Location — Address Assessors Map and Parcel
--- ----------------------
Owner ------------- -------------------
Address
----------------—---------------------------------— -- — —----- --------------
q Installer — Driller Address
Type of Building•-. _
Dwelling —
'Other - Type of Building--=---_—_____________ No. of Persons-------------__________
Type of Well L/-- !�FF _--------__
Purpose of Well 1,6�e -------
,a
Agreement:
The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The
Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to
'?• place the well in operation until a Certificate .of Compliance has been issued by the Board of Health.
t `
Signed ----------—
f O d /
Application Approved By /date
r
Application Disapproved for the following reason : ---_____—_—__________--________________—__—__—__________
date
Permit No. --- Issued--�t '` O` --- ----------------
date
———— ----------------------------1__
BOARD OF HEALTH
TOWN OF - BARNSTABLE
Certificate ®f Compliance
THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired (4-)'
-
-----------------------------------------------------
Installer
at'---- 7" �9.c o,/.
—�--- -- - --- ------
has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection
Regulation as described in the application for Well Construction Permit No.[ Dated-- -------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE---- -- -- - —-- Inspector--- - —- -
BOARD OF HEALTH
TOWN OF BARNSTABLE
Vell Con5truct ion Permit
I )IL�1 _0
NO. - — Fee ----------
Permission is hereby granted
to Construct ( ), Alter ( ), or Repair (�i)an Individual Well at: -
-------------------------------
Street ,r
as shown on the application for a,WelI Construction Permit
No.-_ C/ -— --- Dated---L r C/ -- ------------------------
--
-----------— � _1!f- _-=------- ----------------------
DATE ...
Board of ealth
FORM 11 -SOIL EVALUATOR FORM
Page 1 of 3
No. P9400 Date: 4/6/99
Commonwealth of Massachusetts
Barnstable, Massachusetts
Soil Suitabilty Assessment for On-site Sewage Disposal
Performed By: Samuel Philos-Jensen, E.I.T. Date: 4/6/99
Witnessed By: Donna Miorandi
Location Address or Owner's Name, Mark E. Nelson
Lot# Address,and 307 Willow Street
Same Telephone# West Barnstable, MA 02668
(508) 362-2108
New Construction Repair
Office Review
Published Soil Survey Available: Noo Yes ,
Year Published 1983 Publication Scale 1:20000 Soil Map Unit CcB
Drainage Class Excessively Drained Soil Limitations Severe: poor filter
Surficial Geologic Report Available: No , Yes
Year Published Publication Scale
Geologic Material (Map Unit)
Landform
Flood Insurance Rate Map:
Above 500 year flood boundary No Yes .
Within 500 year flood boundary No Yes ❑
Within 100 year flood boundary No ❑ Yes
Wetland Area:
National Wetland Inventory Map (map unit)
Wetlands Conservancy Program Map (map unit)
Current Water Resource Conditions (USGS): Month February
Range : Above Normal ❑ Normal Below Normal .
Other References Reviewed:
FORM 11 -SOIL EVALUATOR FORM
Page 2 of 3
Location Address or Lot No. 307 Willow Street
On-site Review
Deep Hole Number 1 1 Date: 4/6/99 Time: 10:00 am Weather Clear, 60OF
Location (identify on site plan)
Land Use Yard Slope (%) 2% Surface Stones None
Vegetation Grass
Landform Terminal Moraine
Position on landscape (sketch on the back)
Distances from:
OpenWater Body 800 feet Drainage way feet
Possible Wet Area 600 feet Property Line 35 feet
Drinking Water Well 152 feet Other
DEEP OBSERVATION HOLE LOG*
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(inches) (USDA) (Munsell) Mottling (Structure,Stones,Boulders,Consistency,%
Gravel)
0-2" O
2" -8" A Sandy Loan 10 YR 3/4
8" -24" B Loamy San 10 YR 5/8 Massive, very friable, 5% gravel
24"-47" C- 1 Fine Sandy 2.5 Y 5/6 42" -47" Massive, very friable, 5% gravel
Loam 7.5 YR 5/8
4%
47" -51" C - 2 Silt Loam 10 YR 5/3 47" -54" Massive, friable
7.5 YR 5/8
1%
51"- 132" C - 3 Sandy Loan 10 YR 5/4 Massive, very friable, 2% gravel,
pockets of silt loam
MINIMUM OF 2 HOLES REQUIRED AT EVERY PROPOSED DISPOSAL AREA
Parent Material(geologic) Glacial Till Depth to Bedrock: >132"
Death to Groundwater: Standing Water in the Hole: 120" Weeping from Pit Face:
Estimated Seasonal High Ground Water: 29' MSL. Standing water observed 10' BGS at time
of seasonally high water.
FORM 11 - SOIL EVALUATOR FORM
Page 3 of 3
Location Address or Lot No. 307 Willow Street
Determination for Seasonal Hiph Water Table
Method Used:
Depth observed standing in observation hole 120 inches
❑ Depth weeping from side of observaqtion hole inches
❑ Depth to soil mottles inches
Uround water adjustment 1.2 teet
Index Well Number SDW-252 Reading Date MARCH, 1999 Index well level 47.1 feet
Adjustment factor 1.2 feet Adjusted ground water level 30.2 feet (msl)
Depth of Naturally Occurring Pervious Material
Does at least.four feet of naturally occurring pervious material exist in all areas
observed throughout the area proposed for the soil absorption system? Yes
If not, what is the depth of naturally occurring pervious material?
Certification
I certify that on 10/98 1 have passed the soil evaluator examination
approved by the Department of Environmetal Protection and that the above analysis
was performed by me consistent with the required training, expertise and experience
described in 310 CMR 15.017.
Signature Date
{
FORM 12-PERCOLATION TEST
i
Location Address or Lot No. 307 Willow Street
COMMONWEALTH OF MASSACHUSETTS
i
West Barnstable, Massachusetts
i
i
Percolation Test*
Date: 4/6/99 Time: 10:40 AM
Observation Hole # 1
I
Depth of Perc 40"-52"
Start Pre-soak 10:40 AM
End Pre-soak 10:55:00 AM
Time at 12" 10:55:32 AM
Time at 9" 11:01:18 AM
' Time at 6" 11:05:48 AM
Time (9"-6") 4:30 Min.
Rate Min./Inch 1:30 Min. /In.
* Minimum of 1 percolation test must be performed in both primary area AND
reserve area.
i
Site Passed Site Failed
Performed By: Samuel Philos-Jensen
Witnessed By: Donna Miorandi
Comments:
f
'i Y :
Permit Number: �` Date:
Completed by: 55
HIGH GROUND-WATER LEVEL COMPUTATION
Site Location: 307 Ui 11ou) Sire- Lot No.
Owner:_-Mar-/ F. .�fSDn Address: 3!:�17 tf,Ilo+..,
Contractor: Address:
Notes:
STEP 1 Measure depth to water table � G 1
10 U
to nearest 1/10 ft. .............................................................................. Date i, /day/near o
STEP 2 Using Water-Level Range Zone
and Index Well Map locate
site and determine: s b w 2 S2
OAppropriate index well.................................................
OWater-level range zone .....................................................
STEP 3 Using monthly report "Current
Water Resources Conditions"
determine current depth to A n I-G) lI y�.
water level for index well ........................:. / G �t
month ear
STEP 4 Using Table of Water-level Adjustments
for index well (STEP 2A), current depth
to water level for index well (STEP 3),
and water-level zone (STEP 2B)
determine water-level adjustment ......................................................................
....................
STEP 5 Estimate depth to high water
by subtracting the water-
level adjustment (STEP 4)
from measured depth to water
levelat site (STEP 1) .............................................................................................................
Figure 13.—Reproducible computation form.
15
Table 6. Potential water-level rise, in feet for
i
use with index well Sandwich SDW-252
WATER ZONE A ZONE B ZONE C ZONE D
LEVEL
45.9 0.0 0.0 0.0 0.0
46.0 0.1 0.2 0.2 0.3
46.1 0.2 0.3 0.4 0.5
46.2 0.3 0.5 0.6 0.8
46.3 0.4 0.6 0.8 1.0
�
46.4 0.5 0.8 1.0 1.3
46.5 0.6 0.9 1.2 1.5
46.6 0.7 1.1 1.4 1.8
46.7 0.8 1.2 1.6 2.0
46.8 0.9 1.4 1.8 2.3
i
46.9 1.0 1.5 2.0 2.5
47.0 1.1 1.7 2.2 2.8
47.1 1.2 1.8 2.4 3.0
47.2 1.3 2.0 2.6 3.3
47.3 1.4 2.1 2.8 3.5
47.4 1.5 2.3 3.0 3.8
47.5 1.6 2.4 3.2 4.0
47.6 1.7 2.6 3.4 4.3
47.7 1.8 2.7 3.6 4.5
47.8 1.9 2.9 3.8 4.8
47.9 2.0 3.0 4.0 5.0
48.0 2.1 3.2 4.2 5.3
48.1 2.2 3.3 4.4 5.5
_ 48.2 2.3 3.5 4.6 5.8
48.3 2.4 3.6 4.8 6.0
48.4 2.5 3.8 5.0 6.3
- 48.5 2.6 3.9 5.2 6.5
48.6 2.7 4.1 5.4 6.8
48.7 2.8 4.2 5.6 7.0
48.8 2.9 4.4 5.8 7.3
48.9 3.0 4.5 6.0 7.5
49.0 3.1 4.7 6.2 7.8
49.1 3.2 4.8 6.4 8.0
49.2 3.3 5.0 6.6 8.3
49.3 3.4 5.1 6.8 8.5
Replaces Table 6 in
Cape Cod Commission
Technical Bulletin 92-001 Page 1 December 16, 1992 .
No....:5- Z:.......... Fx$...A`o v...........
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
............OF..........
0.7 ................................
Applirativit for Dislimal Works Tonstrurtion Punfit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
l.0 C P- 0d9�1 STD
aS� Du..IO ....LAddress or Lot N
� �GT r�GaS�
G
......... .... ............. ........... .................................... ........................-•---------...---- ------............................................
Owner Address
W
� .............................................Installer......................................... ............................................Rddress....-----.._............................---
Type of Building Size Lot.....9z 04.•0.0.40.Sq. feet
►-� Dwelling—No. of Bedrooms...........3.................................Expan`sion Attic ( ) Garbage Grinder ( )
04 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures ------------•---•-----•---- .......................................
W Design Flow.__.... ...........................gallons per person per day. Total daily flow........�.Q.,O........................gallons.
WSeptic Tank—Liquid capacityf4.,b_ .gallons Length................ Width................ Diameter................ Depth................
Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area_3d.'?7�.sq. ft.
Seepage Pit No.ZO-Q_�__:___- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water-_._-_.-_.-_.__-____._.-
f� Test Pit No. 2................minutes per inch Depth of Test Pit..................... Depth to ground water.................__-___.
N ------.•.--•.................•--.........•--........................................
O Description of Soil.................5./ ltiG�.:. ............... ................................
x i.AAA�6G
U .-•••----••-••--•---•-•-•-•-••-••--------••--•••- --•---•••----••-•••••••------•••--••---...----••-•----•--------•--......••--- ................................
W
U Nature of Repairs or Alterations—Answer when applicable..._............................................................................................
-- -- -- - - ----------------------------------- ---------- ---------------------------------------------------------------•----•--••••.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code— e undersigned further agrees not to place the system in
operation until a Certificate of Compliance has n issue he o rd of ealt
Signed 7-
a
Application Approved BY
........................................
' Date
Application Disapproved for 2e following easons:----•-----------------•-•------••••••-----...--••-----------•---•••---•--••-•••-----••--••-•--•-•-----•••.......
-----...-•-------------••----•--....----------------------•-......--•-----------•--------•--------------•-----------------•--------------------------------------....-----------•---•-••••••----••------
` Date
Permit No........Lrl.l------------------------------------ Issued...... .
Date
THE FOLLOWING
IS/ARE THE BEST
IMAGES FROM POOR
QUALITY ORIGINALS)
I M ^C&L
DATA
...................No.......1`1..............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
F. ..........�......... . .......... 0 er _.................................
Applirat Wa for Diaposal i8orkg Tonstrurtion Prrutit
Application is hereby made for a Permit to Construct 'X) or Repair an Individual Sewage Disposal
System at:
............... .
............. ...... .........................................
...... ...
... ........I......... .................... ..... ..
... . ........... ...............
Location 7.Ad4rFss or Lot No.
....................................................:. .. .................. ................ .................................................................................................
Owner Address
.......... ......... ...
Instal ler Addres s
00 " �9
14 Type of Building Size Lot........: 9 q. feet
U
Dwelling—No. of Bedrooms....... ................................Expansion Attic Garbage Grinder ( )
Other—Type of Building ..........................'—No. of persons............................ Showers Cafeteria. ( )
PL4Other fixtures .............................. ........................................................................................e..............................
Design Flow...........e—.............................gallons per person per day. Total daily flow..........
W j.......................gallons.
9 Septic Tank—Liquid capacity K,.'...."._`gallons Length________________ Width_._._.._.-._..._ Diameter._._--.._.______ Depth__._________-_-.
Disposal Trench—No. .................... Width.__..___._.___...__. Total Length_.__._..._.__._.__._ Total leaching area...................sq. f t.
Z z, 1 -
Seepage Seepage Pit No..A-:1..,f)...... Diameter____________________ Depth below inlet..._.___.....__.._.. Total leaching area...................sq. f t.
Z Other Distribution box Dosing tank
Percolation Test Results Performed by.......................................................................... Date____________________.____________.____..
Test Pit No. I................minutes per inch Depth of Test Pit....__-..____...___. Depth to ground water______________________-.
rZ_1 Test Pit No. 2................minutes per inch Depth of Test Pit_--______________.__ Depth to ground water_...__.___.__._.._._....
.............................................................................. ..............................................................................
Description of Soil------------------ r ..................�'A.,i,!,.L,"?;:.&_._n............... ------- -----------------
77!1
U .............................................................................. ......................................................f.:... ...... ........
.......................................................................................................................................................................................................
U Nature of Repairs or Alterations—Answer when applicable.-.,............................................................................................
..................................................................................................................................... ..................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article X I of the State Sanitdry.R-6�e—_T�b undersi I gne��, uither agrees not to place the system in
operation until a Certificate of Compliance haslbeerr`gstli6d Py the bbar4A-th5allth. rj
;p", f
Signed... ................................:.............. ............................... .........
1 a�c
ApplicationApproved,.By........................................................ .......................................... ........................................
I I A, Date
Application Disapproved for the fpllazvih recr ................................................................................................................
f
............................................................................ .........................................................................................................................
Date
PermitNo......... .................................. Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH '
..........................................OF....................................................I.........I.....................
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired
Z
b /I -y............... ....... ...................................
Installer
at.......... ..........----------------................. ............ ....................I..........................................................................................................
has been't'inftaltAtin as des -'I d in the
�qf? .' . _ c " -7,
application for Disposal Works Construction Permit No------------------------------------------ dated-..........
/7.................
THE ISSUANCE OF THIS CERTIFICATE SHALL NbV/gE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE........................ ....................................................... Iais,P .......7............................................................................
THE,COMMONWEALTH'OF MASSACHUSETTS
BOARD OF HEALTH
.............;O.e� ...................OF............. .................No.
7, •A", FEE.__.. ..............
Permission is hereby granted...Ln4,e............4.Wit'_: 1_................................................................................................
I . 'If-
to Construct or Repair ,an Individual Sewage- Disposal System
at No......... ...............................................................................................................................
.............
Street
4� 4"
0 S4
as shown on the appiicatl;b* n for Disposal r s Construction Permit .No.__...........f........ ............
........... ..................
------
of Health
DATE ,d ----.......
FORM 1255 HOBBS a, WARREN, INC-. PUBLISHERS