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HomeMy WebLinkAbout0166 CARRIAGE LANE - Health 16,bCarriage Lane,; o a 0 . � y Commonwealth of Massachusetts AIQ Executive Office of Environmental Affairs �i De artme nt of Environmental Protection e n Wltllam F.Weld 1 Trudy Coxe Governor A►geo Paul Celluccl s.oretnry U.Governor David B.Struhs commasioner SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A _ CERTIFICATION ` ) Property Address: M/say %/4 Adde+eas of O er.RECEIVED Date of Inspection: (It different) Name of Inspector. A U G Q p 1997 Company Name,Address and Telephone Number. HEALTH DEFT. CERTIFTIO STATEMENT 2�' OF BARNSTABLE IlrA ', 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 sewage disposal systems. The system: Passes _ _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ F Inspector's Signature: Date: . r 1.7 The System Inspectors 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. INSPECTION SUMMARY: Check A, B, C,or D: p f i 1 A) SYSTEM PASSES: h i 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. BJ SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection._ P Indicate yea,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,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 ponforming septic tank as approved by the Board of Health. (revised 11/03/95) 1 One Winter Street • Boston,Massachusetts 02106 • FAX(617)556.1049 • Telephone(617)292-5500 i~J Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner, Date of Inspection: BI SYSTEM CONDITIONALLY P ES (continued) Sewage backup or b out or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,sett or uneven distribution box. The system will pass inspection if(with approval of the Board of, Health): broken pipe(s)are replaced t obstruction is removed r ribution box is levelled or.replaced 1+ The system'required pumping m re than four times a due to broken or obstructed pipe(s). The system will pass inspection if(with approval of th Board of Health}- broke pipe(s)are laced . :. . ••.. obstru ion is re oved ,4 CI FURTHER EVALUATION IS REQUIRED BY E OARD OF HEALTH: [ Conditions exist which require further uation by t Board of Health in order to determine if the system is failing to protect the + " public health,safety and the enviro ent. �+ 1) SYSTEM WILL PASS UNLES BOARD OF HEALTH TERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PR TECT THE PUBLIC HEAL AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy ' within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated tland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND P LIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES THAT THE SYSTEM 1S FUNCTIONING IN A MAN THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: ( The system h'al a septic tank and soil absorption system and is within 00 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and 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 leas than 5 ppm. 3) OTHER (revised 11/03/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM r. PART A CERTIFICATION(continued) Property Address: Owner. Date of Inspection: D) SYSTEM FAILS: I have determined that the system vio tes one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. a Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or m component due to an overloaded or clo SAS or cesspool. Discharge or ponding of effluent to th surface of the ground or surface rs due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box ve outlet invert due an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6"belo invert or av ' ble volume is less than 1/2 day flow. Required pumping more than 4 times in the ye NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System, 1 or privy is below the high groundwater elevation. Any portion of a cesspool or privy is azt 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is 'thin a Zone'I o a public well. Any portion of a cesspool or pri is within 50 feet of a 'vate water supply well. Any portion of a cesspool or rivy is less than 100 feet but ter than 50 feet from a private water supply well with no acceptable water quality ysis. If the well has been anal ed to be acceptable, attach copy of well water analysis for coliform bacteria,volatil organic compounds, ammonia nitro n and nitrate nitrogen. E) LARGE SYSTEM FAILS: The following criteria•app to large systems in addition to the criteria abov The system serves a ty with a design flow of 10,000 gpd or greater( System)and the system is a significant threat to public health and safety an the environment because one or more of the following co ditions exist: the m is within 400 feet of a surface drinking water supply the m is within 200 feet of a tributary to a surface drinking water supply _ system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone II of a public ter supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program . requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.. t (revised 11/03/95) 3 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner. Date of Inspection: Check if the following have been done: ✓Pumping information was requested of the owner, occupant, and Board of Health. e" 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. ! Pfie system does not receive non-sanitary or industrial waste flow E' tf'ge site was inspected for signs of breakout. //All system components, excluding the Soil Absorption System, have been located on the site. F, 41%e 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. "e size and location of the Soil Absorption System on the site has been determined based on existing information or ;1 approximated by non-intrusive methods. &'Ke facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11/03/95) 4 f �f 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: n Owner. Date of Inspection: _ l� FLOW CONDITIONS RESIDENTIAL- Design ,�Ballons Number of bedrooms: Number of current residents: Garbage grinder(yes or no): Laundry connected to system or no): Seasonal use(yes or no): Water meter readings, if available: Last date of occupancy:? COMMERCIAL/INDUSTRIAL. Type of establishment: Design 11ow:__p1lons/day 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: OTHER(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORnd source of information: System pumped as part of inspection: (yes or no)_ If yes,volume pumped: gallons Reason for pumping:. TYPE�YSTEM , 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) Other(explain) APPROXIMATE AGE of all components,date installed(if known)and source of information: Sewage odors detected when arriving at the site: (yes or no)/�C✓ (revised 11/03/95) b SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM E PART C SYSTEM INFORMATION (continued) Property Address: ,, II aa U—a' Owner. Date of Inspection: SEPTIC TANK� (locate on site plan) Depth below grade: �'—_ Material of construction:v ncrete_metal_FRP_other(explain) Dimensions: Sludge depth: 16 _ /2 "/ lI Distance from top of sedge to bottom of outlet tee or baffle: Scum thickness:_ Distance from top of scum to top of outlet tee or baffle: 3 Distance from bottom of scum to bottom of outlet tee or baffle:_ Comments: (recommendation for pumpir►�dition of inlet and out t tees or baffle ,depth of liquid_level in relation to outlet ' vert, struct ty, evidence of leakage, etc 1 — s GREASE TRAP:_ (locate on site plan) Depth below grade: Material of construction: _concrete_ tal_FRP_other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee o e: Distance from bottom of scum to botto tlet tee or baffle: Comments: _ (recommendation f ping, condition of inlet and outlet tees or baffles, depth of liquid a in relation to outlet invert,structural integrity, evidence etc.) (revised 11/03/95) 8 , i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oontinued) Property Ad Owner. s Date of Inspection: TIGHT OR HOLDING TANK— (locate(locate on site plan) Dep below grade: Mate construction: concrete_metal_FRP—other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, ion of alarm and float switches,etc.) ; DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: 0 Comments: (note if level d distnbutio is ual, evidence of p lids carryove ,evidence of le t or out of box, PUMP CHAMBER_ (locnroe oa siteLpla=n)Pumps in wor o er: o Comments: (note condition of pump chamber, condition of pumps and appurtenances, (revised 11/03/95) 7 • •i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C // SYSTEM INFORMATION(continued) Property Address: Owner. S _. Date of Inspection: �rl L r? SOIL ABSORPTION SYSTEM (SAS). (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: chambers,number: ((// �8 chain leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool,number: tax ( condition of soil, s' of by uli f 'ure, level of ponding, conditio f vegetation,etc.) CESSPOOLS:_ (locate on site plan) Number and co r tion: Depth-top of liquid to ' invert: " Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow(cesspool must be pumped ea of' ion) Comments: (note condition of soil, s' of hydraulic fail level of ponding, condition of vegetation,etc.) PRIVY:_ (locate on si Ian) of construction: Dimensions: De of solids: tax (note condition of soil,sips of hydraulic failure,level of ponding,condition of(vegetation etc.) (revised 11/03/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: lb Owner: Date of Inspection: z -� SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' r; od 13 ;LL o DEPTH TO GROUNDWATER Depth to groundwater:_ feet method of d ter inatio o(� gr approximation: A , (revised 6/15/95) 9 TOWN OF BARNSTABLE -080 Q t LOCATION SEWAGE # � a� VILLAGE �� ASSESSOR'S- MAP & LOT C, I INSTALLER'S NAME & PHONE NO. �� ✓�CZ �S� 7t� SEPTIC TANK CAPACITY lit LEACHING FACILITY:(type), (size) NO: OF BEDROOMS V PRI ATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: -�Z VARIANCE GRANTED: Yes No, � �� 9 mot,/, OR No. !'' '. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALT TOWN OF BARNSTABLE ApplirFation for Biipooal Workii Tonotrnrtion Vamit Application is hereby made for a Permit to Construct (L.#) or Repair ( ) an Individual Sewage Disposal System at ................_G_c J G ......_. � . ...... . o. . L Adds ..... .... ?.�1G...�_c.am....N-�o�..._...:..... �9T'�.7..Q.........�= - .................................... .......... ' el .....�...y./em. s/_1'T Owner ���. Address a ...........�G/e _.!_0...--...a® `:C .�......•----•---•-•------------ •-•--•-•---------- .................•--........................... Installer Address Type of Building Size Lot... .... . Sq. feet a 17 Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage inder ( ) p., Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures ............................ . W Design Flow.................. 5................gallons per person per day. Total daily flow.............., 3..c.�..............gallons. d WSeptic Tank—Liquid capacit/_5��.gallons Length�9.`~o.. Width..�.�®_ Diameter................ Depth.All ®_. x Disposal Trench—No..................... Width... ............... Total Length..........-........ Total leaching area....................sq. ft. Seepage Pit No----------l------- Diameter.lZ_' _._. Depth below inlet.# ._..�...... Total leaching area.7�.,sq. f+. z Other Distribution box ( [)-"- Dosing tank aPercolation Test Results Performed by..L-rol �� Date---`.��.��$Z......... Test Pit No. 1 ....minutes per inch Depth of Test Pit./3-•--_....... Depth to ground water_.. ors ' Gr4 Test Pit No. 2 ._-7-..minutes per inch Depth of Test Pith 3_z_Y_._. Depth to ground water`iS_�.wc. 0 •-------------------------------------•--- ---••---•- ----------•-•------•----------------..---------......---•----•--._...-•----•-----.........----.-- 0 Description of Soil....... =�z �....�-'��J� r� L } - 2 --- y -----p -- ---...........��----=-------�=-------.�'_�_.�.�®.ram-,----�Y---�'..��----- v4`=�'��✓ y�/��y � f car / c j r `Z' f',� � �± ...... !/ ...... . W ... ... iG__V_ ..._ ------------------________________ / h+Ti .._ .. .............. 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 TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance ed y the of health. l Si ned - . g ------ ---------- ------------------ ----- -------- ------------------------- Application Approved By ..-.: 4'� 3 :.................. ..... ..... ----------.--...........................------ ......... .�..... :....� �- Date Application Disapproved for the following reasons: ....................................... ............................................ ............... Date Permit No. ..- ! ................................................... Issued ............Z.....'r`.�*"Y. Date Fic...�...�......:..... THE BOARD LTH OF F OF HEALTH T�� TOWN OF BARNSTABLE Appliration for M-4po al Works Towitrurtiart rumit Application is hereby made for a Permit to Construct ((.-Ij o Repair ( ) an Individual Sewage Disposal System at: ................----'4......,T�i�r�..c �.... ... �'�"" .<,�,� ..��-�?��. ........... ? .oCajb •Address or t - ..........-•--�7........ ..................... ..........--.............................-.-.---......----•-•-- .....................--....17 Owner Address W� ..................... ................. ....•-............•••............. .... goInstaller Address d Type of Building Size Lot.._. 1:. Sq. feet Dwelling—No. o= Bedrooms................�w'___.......___..__..___.___Expansion Attic ( ) Garbage G nder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures . ---------------------•------------------------ W Design Flow.................. -__ --.----._.-gallons per person per day. Total daily flow...............3�'_.��_....__......gallons. WSeptic Tank—Liquid capac>ty/7-3—P.gallons Lengthl _.-4_._ Width_. ."9.._ Diameter---------------- Depth.- Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. • Seepage Pit No----------/------- Diameter.,_Z__'.5?.` Depth below inlet__'_ ?. '__ Total leaching area__��,�y-_.Ca_._sq,ft,- Z Other Distribution box Dosing tank Percolation Test Results Performed by._ .C� -__._------- /"Date..__ ......... �C ......... Test Pit No. 1�._Z-____minutes per inch Depth of Test Pit. ___..__. Depth to ground water.......A- s^" fT4 Test Pit No. 2..=_7_._minutes per inch Depth of Test Pits'3._Z_.._.. Depth to ground P+ ----••-----------------------• -----•-••---------•••••••.........•....-•-••••--•••.-•-•• ..............-•-•-----•••----..............-•-•--•---•-----.•••-- O Description of Soil__.____._.f .___._.___ ?5�6�---. �•• r --- -_.. V -/ I -••-- 11-'1�r `"J /Ce7� / C cam .. '�1�c .o.� ......................V� 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 TITLE 5 of the State Environmental Code - The undersigned further agrees not to place the system in operation until a Certificate of Complian eS �""e su d by thei��axa of health. G� t:�/v Signed -- ---------- - .......................................... Application Approved By .............. .. ........................ ...... .. . 7�7 Da .---- F .•s � Q Date Application Disapproved for the following reasons: ................................ ------------- ----------- ... ................................................................................... ---- ---- --------------------- -- -------------------- ----- ---------------------------------------------------------------------- Date Permit No. --- ...��. '�+ .- ...... Issued ---------- '41 — /'�'..7 ---- ----...................... Date THE COMMONWEALTH OF MASSACHUSE17S BOARD OF HEALTH _ TOWN OF BARNSTABLE (IT r#ifira e a Clain"Xia nre THIS V TO�?ZTIFY, Thy t e In ividual Sewage Disposal System constructed ( Y ) or Repaired ( ) by.......................... . r at ---'-----tel. If ..-I//— J�------- ,", ,/I �'/ fl.. '�na"mn�et� ��"�/L/ .-T �--•.f --------------------- has been installed in accordance with the provisions of TITLE 5 ss f The State Environmental Co eras/ cr..ede the application for Disposal Works Construction Permit No. ...... .. ....4?-_`�..... dated ...... ....................................... 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 TOWN OF BARNSTABLE No........................ FEE...�w.�J Permissionis hereby granted.............................................................................................................................................. to Construct (Y. or Repair an Individual Sewage Disposal S..stem at No. j� ..: '1...�" .?�` P Ali 9 `T—if L'Q .............................. ----------••-• -----•••••-••••••----•••......-•••.............. as shown on the app cati®n for Disposal Works Construction mit Street No. �'��hatedd.nk' _.`^ ter• �O r / Boa ---f r ------------------------------ DATE............... --- --f•-r..._ .. ............................... Boa f Health FORM 36508 HOBBS&WARREN,INC..PUBLISHERS THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ................ ApplirFa#ion for Disposal Works Toaastz- uon, Vrrmit Application is hereby made for a Permit. to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ................. ................................................... - • Location-Address or t No. .... �'�`�- •- p k ©-- BS.OI�c........mc ;.. rs _... _. - ... Owner _, a Address w .. Installer Address U Type of Buildifig Size Lot 3J`*9.z= ....Sq. feet Dwelling—No. of Bedrooms................................. ....Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building ...... No. of persons............................ Showers QI YP g -••----------•-----•-- P ( ) Cafeteria ( ) a .. -------•-----•-•----•....... � Design Flow.................................?�- lions er erson r ....---••............ ..........•-•------•------•--••-•---•--...--•-•--..._.................. Other fixtures ........ ....... .... . . w 1g P P g dadthAa . Total daily flow..................•.33 O._......s bins. WSeptic Tank—Liquid*capacity/Z,�Q -..._._gallons Lengt . O.:_ Wid .." ^.. Diameter... ... Depth... g �� x Disposal Trench—No..................... Width�........�....... Total Length.......r._...... Total leaching area....................sq. ft. Seepage Pit No.........../........ Diameter.Z.�Z_.-.O... Depth below inlet.6.._-P----- Total leaching area.54-.la-..*gr-k.4Ap z Other Distribution box (K) 'Posing tank ( ) a Percolation Test Results Performed by._--{-1_-d.S. ✓� x_: Sloe IP�<,y..... Date.....-�QYI... Test Pit No. I........f....minutes per inch Depth of Test Pit....1-8.Q..... Depth to ground water....,d,C,x7sr... (z, Test Pit No. 2......4_....minutes per inch Depth of Test Pit.... .0.... Depth to ground water....../'�:Q.t2 .. ........ Description of Soil..��jj'..... T ftS�21..� u., 0 1. 3- •�- ,�...._,�[iG :!" a ..... w .-••-••-------•--' -------------------------------------------------------------------•--------------------------------.......... U Nature of Repairs or Alterations—Answer when applicable...................................................................:........................... rsigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with efrgovi f TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in c� or trtron a Certificate of Compliance has been issued by the board of health. SPAT;i j #11129 5 v►`"� Signed...................................................................................... ................................ D210 APproved By.- - a Zy, �.............•-•-----..----- �� ' ` Date plication Disapproved for the following reasons:.............................................................................................................. .................................. ..............................-•-----'------.......................................----------'-------'------•---------•-------•---'--------------••--•I--•----•------•- •- _-•.-Date- Permit No...... �.'.. -_.?,...._...._.. Issued._.....�j�_/� . Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............ ..... OF...S. .e.tjSV. 4 <P................................ fitrr��f�rtt�r of �um�lt�nrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by...............................................•.....-•------...-•----------._...._.....---------- --------......_...-------••--•--•-•-•••-•.....--•........ ...-- _..... ...-•-- Installer at........................................................................................................................................................................................ .... has been with the provisions of T n, m �Q r <'��tr � �_� the application for Disposal Works led in eConstruction Permit iVo--- --- � of State Sanitary s (fc - din 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 No.. �G:..: �i ......,.�.. .1/!!..!4..............OF....1�/4�2N. Sr /�.L ........................... FEE... ✓Disposal Works ,Tonstr ion Fermi# Permissionis hereby granted.....................................................................................'--------•---•--......:........................••--...... to Construct ( ) or Repair ( ) an Individual Sewage Disposal System atNo.................................................................................................................................. ' Street as shown on the application for Disposal Works Construction Permit No..e ted..... ....... ........................•-----...---.....------••-------------..........---.....--------••-•-•-•...---•-- DATE. Board o£ Health '._._.---'--'-------....-•..................................................... / FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH .........................to a. ,-�....OF...0 ..­ ...... ......AIS A-.... It r5€... � Appliratilan for Difivasal Works.. Tunstrurtiun ami# Application is hereby made for a Permit to Construct V ) or Repair ( ) an Individual Sewage Disposal - System at ........................................ ...........-•--•----------................... -•-.......- . /Location Address ..� I.C)0'J?C.:�7.c*'�.a� ..... 0 ...../ Owner Address w Installer Address w, QType of Building Size Lot-..'5:!. -.�.....Sq. feet Dwelling=No. of Bedrooms...........:....................... Expansion Attic ( ) Garbage Grinder ( ) '4 Other—T e of Building .. No. of persons............................ Showers — Cafeteria a' Other fixtures ...........................................-.............................................. w Design Flow................................. _..gallons per person per day. Total daily flow........................._Q..........._...gallons. WSeptic Tank—Liquid ca.pacityq so gallons Length✓''�."_�... Width='-�=�_.�. Diameter.__- Depth................ x Disposal Trench—No..................... Width.................... Total Length-------------_.....,Total leaching area....................sq. ft. Seepage Pit No.............. Diameter->�'.......O..._ Depth below inlet ..f-.Q..... Total leaching area. Z Other Distribution box ( ) Dosing tank ( ) _ 0-4 Y.................................t o­ _.�. ,: . , ,. l n � Date. _j o V1 -.2--J �c a Percolation Test Results Performed b " .. t :_`?� ...... ........ c Test Pit No. 1........1-----minutes per inch Depth of Test Pit.... ...... Depth to ground water-___fi_ 44 Test Pit No. 2......4......minutes per inch Depth of Test Pit---- -__- Depth to ground water........... O Description of Soil..,") '�7. j - --- t`�_,{� 8 f 3 e �...__...........................................< �` a . , _. P r yi w U ,w. Repairs or Alterations—Answer when applicable---------------------------- -------------------------------------------------------------•---- .. . _° . --•------------------------------•----------------------------•------•-••--------•--•----------------------------------- eem o The a ed agrees to install the aforedescribed Individual Sewage Disposal System in accordance with Ft; WA TER. ' the pgovislon T LE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in 0P 0 . nt a ertificate of Compliance has been issued by the board of health. Signed..................................................................................... ................................ :Approved BY . -•-•--••-- f7Date Application Disapproved for the following reasons:.. ------••----------------------------------------------------------....................... ---------------------•------- --------- ------------•--------------•--------•----.--------------------------- --------- •---------------------------------------------------------•------------ Date Permit No...... �� ............. Issued------- __ %_/ P----------------- ... ......... ..... . /1Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ' r,®......................................................... ...........�.... ti...........OF.. ,A 1ZZ i— (9rdifirtt#r laf ToutpliFanre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) bY..................................................................................................................................................................................................... Installer at........................................................•--•••-----•......--•-•---••••-•-•--•-- has been installed in accordance with the provisions of T-!"Li 5 of The State Sanitary Code as d scri ed 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................................................................................ Inspector................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH G AV ` i t . ......................... .............. . ...� i FEE.. Ropos al Work. Tons#rnrtuan ramit Permission is hereby granted......................................................................... ....----•---•-------------------------••......--................._.. to Construct ( ) or Repair ( ) an Individual Sewage:Disposal System atNo.............................•-•--...........----•-------........_._........•.......---•-----...-----------------------------------------------------•---------------...--••-••-••-........... Street as shown on the application for Disposal Works Construction Permit No..,Of� �.� f'ated-----/ _ ,y�• ........ Board of Health DATE................................................................................ FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS 1. 19 � -7-7 i L oT44 3s , 927� eL N t��N I� 1 , N SST ` -78 ` lr /C/TANK C.. /L ` � _ — �'(o �' •. .r `•� u"4.56L.� S��P't42' a !7� �D R V. C. 3 gEo ` T 00 BZ — , _ao � ► WALTER 4'. E. SMITH JR. ROSA L PLA HIV/L �FciTE�° J�•y ,�• D D A b Nc A�s�-o►� M I LLs, M . f-�O S Er.1c-�cz. AS-�oc. 1Nc. OC-T. 19e9 72.0 1OoD (Sal. 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