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HomeMy WebLinkAbout0067 COBBLE STONE ROAD - Health 67 COBBLESTONE RD, BARNSTABLE. A= 316-049. 002 z .i t ' BORTOLOTTI CONSTRUCTION,INC. " 765 WAKEBY ROAD,MARSTONS MILLS,MA 02648 508-171-9399 508428-8926 FAX: 508428-9399 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM . PART A CERTIFICATION Property Address:G 12�_Q444&x� Date of Inspection: 3 ,Q Inspec is Name: Ow er's Name and Address: CERTIFICATION STATEMENT: I certify that I have personally inspected the sewage disposal system at this address and that the informa- tion reported below is true,accurate and complete as of the time of inspection.The inspection was per- formed based on my training and experience in the proper function and maintenance of on-site sewage disposal syst . The System: Passes Conditionally Passes Needs Further Evadation By th Local Aproving Authority Fails Inspector's Signature: Date: The System Inspector shall submi(a copy of this inspection report to the Approving authority within thir- ty(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: A)SYSTEM P S: 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. r , B)SYSTEM CONDITIONALLY PASSES; One or more system components need to be replaced or repaired. The system,upon comple- tion of the replacement or repair, passes inspection. Indicate yes, nor,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 sep- tic tank is replaced with a conforming septic tank as approved by The Board of Health. Sewage backkup 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): - 1 - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Broken pipe(s)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)FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by The Board of Health in order to determine if the system is failing to protect 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: 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 APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTION- ING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and 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 is with 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 the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. D)SYSTEM FAHS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of efluent 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 clog- ged 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 -2- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) 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 it 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 lias been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E)LARGE SYSTEM FAILS: The following criteria apply to a large system in addition to the criteria above: The design flow of a system is 10,000 god 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:" 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 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. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Check if tie following have been done: Pumping information was requested of the owner,occupant,and Board of Health. ' �1`Ione of the system components have been pumped for atleast 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. ,.-4s-built plans have been obtained and examined. Note if they are not available with N/A. _j, ne facility or dwelling was inspected for signs of sewage back-up. _y-The system does not receive non-sanitary or industrial waste flow. _�he site was inspected for signs of breakout. r/All system components,excluding the Soil Absorption System, have been located on site. The septic tank manholes were uncovered,opened,and the interior of the septic tank was in- spected for condition of baffles or tees, material of construction,dimensions,depth of liquid, epth of sludge,depth of scum. The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. -3- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST(continued) The facility owner(and occupants,.if different from owner)were provided with information on the proper maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION / FLOW CONDITIONS •.p it}� J . r 3 t�7 {.t r' Yf�k';^3r .•.t lrf i ra'i. Design Flow: o allons Number of Bedrooms: Number of Current Residents: 'G Garbage Grinder: Laundry Connected i'o System: Seasonal Use: .[ 0 Water Meter Readings,if Table: v Last Date of Occupancy: CO MERCLAL(INDUSTRI_AI_: 100 Type of Establishment: Design Flow: gallons/day Grease Trap Present: (yes or no) Industrial Waste Holding Tank Present:- Non-Sanitary Waste Discharged To The Title V System: Water Meter Readings,If Available: Last Date of Occupancy: OTHER: Describe) Last Date of Occupancy: GENERAL INFORMATION � Q PUMPING RECORDS and source of informati n: Pit/Y)tD �O�p •�� System Pumped as part of inspection: If yes,volume pumped: gallons Reason for pumping: TYP"F SYSTEM: Septic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool f J Privy Shared System(If yes,attach previous inspection records,if any) Other(explain): ROXIMATE AGE of all components,date installed(if known)and source of information. Se age odors detected when arriving at the site: AAV -4- t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C GENERAL INFORMATION (continued) SEPTIC TANK: Depth below grade: Material of Construction: %rete metal • r .FRP_: Other (explain) Dimisions:8:.S X 'XS' Sludge Depth: / ' Scum Thickness: Distance from top of sludge to bottom of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Comments:(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid I el in lation outle ' vert,st tural in ri ,evi ence of leaks ,etc.) a � ii J GREASE TRAP:�� Depth Below Grade: Material of Construction:_concrete_metal_FRP_Other (explain) Dimensions: Scum Thickness: Distance from top of scum to top of outlet tee or baffle: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,etc.) TIGHT OR HOLDING TANK: Depth Below Grade: Material of Construction:_concrete_metal_FRP Other(explain) Dimensions: Capacity: gallons Design Flow: f allonstday Alarm Level: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX:/ 40'.- 44 10 Depth of liquid level above outlet invert: Comments: (note if 1 l and distnbuti is equal evid ce of solids carry v)r,evidence of 1 age int or out o box,,,etc.) PUMP CHAMBER:AA) Pump is in working order: Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) SOIfL ABSORPTION SYSTEM(SAS): l/ (Locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: ,'gy'pp: .� } - ..... t,.., 7„ 4'"'Ye! 3 ti: %Si:t-. r,.. rtfd t i,^!t;rt€�� ?+.'Y?.Sr±• k'i Leaching pits,number:__CZ Leaching chambers, number: Leaching galleries,number: Leaching trenches, number,length: Leaching fields,number,dimensions: Overflow cesspool,number: Comments: (note condition of soil,signs of hydr ulic fail a levq of pondi g,con ditio f vegetatio_n, etc j I CESSPOOLS:( Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of Cesspool: .-I Materialsof construction: Indication of groundwater: Inflow(cesspool must be pumped as part of inspection) Comments: (note condition of soilk, signs of hydraulic failure, level of ponding,condition of vegetation, etc.) Materials ofAconstruction: "` Dimensions: Depth of Solids: Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to adeast two permanent references, landmarks or benchmarks. Locate all wells within 100 Feet. a' o . t 3� DEPTH TO GROUNDWATER: Depth to groundwater: Feet Method of Determination or Approximation: -7- Weller& Associates Bayberry Square—Suite 4C 1645 Falmouth Rd.—P. O. Box 417 Centerville,Ma. 02632 Date: March 2, 1998 Barnstable Health Department Barnstable Town Hall 367 Main Street Hyannis, Ma. '02601 Re: 67 Cobblestone Rd., Barnstable, Ma. Dear Sirs: Please be advised that the leach pit installed at the above referenced property under permit # 95-1562 was a 6' x 6' leach pit lined with 4' of washed stone. This leaching pit has a capacity of 813.7 GPD, adequate to handle up to seven bedrooms under Title V. If you have any questions, please do not hesitate to contact us. Very truly yours, ��`1" of�9Ss9 ] DANIEL E, CoAM AMA N ,. CIVIL "„ 32686'c ti Daniel E. Braman, P.E. 3,12,99 "o�F SS/ONAL ENS' fax(508)775-0754 phone(508)775-0735 O TOWN OF BARNSTABLE LOCATION )&46 SEWAGE# VILLAGE / s ASSESSOR'S MAP & LOT34 —o V9—aQ9- INSTALLER'S NAME&PHONE NO. t7.'�O SEPTIC TANK CAPACITY ( � - LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER O OWNE / CO NS!�-9 p PERMTTDATE: /���^�� COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom 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 3 • c/S' G A LJ- s� ° 133 �o f 13f 3� 1. h O Y9- 0o14- No. .................... Fxs... .... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliratiou for Di-tipwial Wgrk,6 Towitrurtion rantit Application is hereby made for a Permit to Construct ( ) or Repair (0< an Individual Sewage Disposal System at: L ddres ... .. , ----- or--.�+n'1�7_ ......L...g...,.........'---.....---.. C. .......4 O - Owner - Address Address ------------------------------•------.......-----------•---..-----•--•-••---•------• --- r-•• d �--•----•--•--------._.....---...... Installer Address Type of.Building Size Lot............................Sq. feet JDwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder -E-- ,Ov o Other—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) j 4 Other fixtures _______________________________ _ _ Design Flow.................. `,?-_..................gallons per person per day. Total daily flow--------------!�7�----------------gallons. x Septic Tank—Liquid capacity—.gallons Length---------------- Width________________ Diameter................ Depth................ Disposal Trench— No. .................... Width.................... Total Length---------�..______. Total leaching area....................sq. ft. Seepage Pit No....... ........... Diameter------10...___.._ Depth below inlet---la.............. Total leaching area..................sq. ft. 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........................ Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water._._-______--__-._--_... a •----•----------------------------•-•-•---•---------•----•-•-•-•-•-•----•-•-•---•--•----••••-------------------------------- •---------•----------------.----- ODescription of Soil..................................................................................... ------------------------------------............_....----•------•............••--- x U w ----- ------------------------------------------------------------- -------------------------------------------------- ----------------------••----••------•-•-----•-•-----•--•••-••••---..........•... V Nature of Repairs or Alterations—Answer when applicable._._... -- �_...... ------------ -4d®-f - _�f!l�'� . ---. �f7 y -.. �'`� y�_ .1�!4cPl ft 7 73ht - t� '7T rST�tI ETC .. ..S£,dF7� Agreement: S y 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 as been is d y the board of health. aSigned .......... ..... ......................... ---- -------------------- ------ .. % RAJ . Date Application.Approved By -- ---- - -- .. ..... --------- ------ ------- ---- ) ............. ........................................ Due Application Disapproved for the following reason : ................................................................................. . - - -- ------------ Date Permit No.- - .. .. Issued . . ...... .......�. / _. Dare � No. f _....... Fss............... ....... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH - TOWN OF BARNSTABLE Applirativit for Uhaipwi al World, Towitrurtion ramit Application is hereby made for a Permit to Construct ( ) or Repair 4(r? ) an Individual Sewage Disposal System at: ' Location-Address �_ ........ ............:G r. ,................ . .......... �...----........................., sr/.a3!_.......---•---•----.... Owner _ f Address W �/�i 71W ii Ct,N a�.J 7(.na G_sA�t2:fI2 V l� „/►/J �!/1 /l lS .................................................................................................. ..........................................r......._......_........._...__.........._.............. Installer Address d Type of Building Size Lot............................Sq. feet U Dwelling— No. of Bedrooms.__-____-_._.___.______________Expansion Attic ( ) Garbage Grinder {— -/1 Q aOther—Type of Building ---------------------------- No. of persons.------------.-_----_---.-_ Showers ( ) — Cafeteria ( ) Q' Other fixtures ------------------------------------------------------------------------------------------- W Design Flow.................. ---------------gallons per person per day. Total daily flow--------------imZ�k................gallons. WSeptic Tank—Liquid capacity. _gallons Length________________ Width---------------- Diameter................ Depth---------------- x Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No-------J(_..._...... Diameter------- 0.'------ Depth below inlet___f:.............. 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-.--__.--____-_--___---- 44 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ 1:4 •---•-•-••-------------------•-••-•••-••••••...-•-••••••••-•---•---•••-..................----•-•---•......................................................... 0 Description of Soil........................................................................................................................................................................ x V •-••--•--•-•--•••-••...•••••...•••••-•••••••----•-•--•-------------••••--••-------••••••--••••----•--•-•••••-----------•-•---••---•----•••••---••------••---•••••••••••-•-•-••••••..................... W U Nature of Repairs/or Alterations—Answer when applicable..._._. __.r4 4�....... .........4A�! ._ r-> ....4.. � !7 "-............Jl.-./...�.-T.................W..�.............TG..!£...:--...............?L...E_............_rSTivt1................TG_� � .... Agreement: S V_S 1Z_"'N 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 as been issued y the board of health. Signed �; �/1�n1..... /,/n-- -- ------------------- ------1.>�y/ .� Application.Approved By ----- � j -/ -------n .....�1 .. /Yt.. X.... .. ------------- ---------------- _.-- ........ ✓ �........... ......... ....,...,- ... �...- . Dare Application Disapproved for the following reasonvf .... ............. . ... ..---------------------------------- Date Permit No. ..... t. Issued ------------ . .............. Y THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE U Qrtifirate of uR�IImplianre THIS IS TO CERTIFY. That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) � by ........_.._.. ��C�`T`_r�.t<cz.t� �b.�/.�.r� �."cam... - - -........... Insrtllrr at ... -................. �.�...........0 G Q .^,J. r:_.... r ...f...... IQST4---- ------------- has been installed in accordance with the provisions of TITLE 5 f The State Environmental Code as described in the application for Disposal Works Construction Permit No. dated ............. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CO STRUEA AS A GUARANTEE THAT THE SYSTEM WILL FU/NCTION SATISFACTORY. ..---------------C�--------. .1...---...1..`5-------------------------- ------------ THEInspector ...__... J ... ---------------------------------------------------- DATE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH QV�S5...—JS TOWN OF BARNSTABLENo.-- Rpnttl Workii Toatgtrurion Vrrutit Permission is hereby granted..........................�� .G !___.___.... � wb..`� to Construct ( ) or Repair ( an Individual Sewage Disposal System atNo......................................417..------.. ------ ...... Street G'may as shown on the application for Disposal '"forks Construction Permit NO --------- r^ / Board of Health I/l .. 1/!..._ DATE...................•-- ,� a`� _. FORM 36508 HOBBS&WARREN.INC..PUBLISHERS '-S C ION • • S E W�G E PIRMIT 10. VILLAGE INSTA LLER'S NAME & ADDRESS nn /144 61Z,i5 117ir,Y//c '3 i i, PARCEL NO: BUILDER OR OWNER DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED 1 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........... .............OF..........46e P l,�sS. _. .� ............... ApplirFation for -Disposal Works Tonstrurtinn lfrrmit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: .......e--w r3L i�srai.� �t G cT --_25..' .........---------•----------- ---- ,-' ----• - - . . ....... .. ... .._..._... Locat' n-Add r s or Lot No. �c .,..f. ...._.. .................... ............................................. ._--- -----.._...... ................ Owner p f� a Ft .IT........... .Y _�/✓ :A✓1!� p ress. f_�1.1� w��" ...... Installer Address Type of Building 13 Size Lot__�tr _....Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage 'Grinder ( ) a'4 Other—Type of Building No. of ersons..._......................... Showers — YP g ---------------------------• P Cafeteria ( .. ....................•••--..•----••-•-•-•-•----•-•--•-•••-................................................................ WDesign Flow........... ���-..._.-----•----__:_..g lions per person per day. Total daily flow....... .a.......................gallons. Other fixtures ..................... .. WSeptic Tank—Liquid ca.pacity..1202q.gallons Length... ........ Width....4._`..... Diameter________________ Depth...`..... xDisposal Trench—No. .................... Width.................... Total Length__............f..._. Total leaching area...............:....sq. ft. Seepage Pit No......./........... Diameter...f.0_.._:..... Depth below inlet......trra.......... Total leaching area 5•`: -sue. �•P.D Z Other Distribution box O Dosing tank ( ) - '-' Percolation Test Results Performed by.....�=o�-?.... -...f4 �'___�! L' --. Date... .-.Z��.' ........ .� Test Pit No. 1...:!!5_9..minutes per inch Depth of Test Pit::_` _ a Depth to ground water.�0 .....4EN' Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground waterL7'00-'j........ �+ -----•--------------- ••----------•----•--•--- ...... ................................................................................................. O Description of Soil............................15E�_...P V ----••---••----------•-••--•••.....-••••.......................... 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 iITLL 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance hs been sued by the b-oayl of health. Signed D to Application Approved By-•---•--..._. ............................. ........ ........ ate Application Disapproved for the Vowing reasons:............................................................................................................... ........................................•..........---••••-------...•--••••-----•......_........--••-•-......._.......••------•-••--------•-•-•-••-----•-----•---•-•••-----...---•-•- -••-•--------- Date Permit No..-- S..... ...-. Issued - Date FEB .................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .. ..........7a k)j.............OF......... .. ApplirFation for DiSposal lVarks T.onstrartion Vanfit Application is hereby made for a Permit to Construct (X), or Repair an Individual Sewage Disposal System at: ....... .............................................21.."�....................................... Loc ' Address or Lot No. ................... .................................................4falw li jL d Owner Address......17................................... �A ..........N1.1 .............. u E 1�A/ . R U//c./�................................. ...... L.... . ............... .................................................. Installer Address Type of Building Size Lot..-f:5,� feet Dwelling—No. of Bedrooms_.......`..................................Expansion Attic Garbage Grinder-'( a Other—Type of Building ............................ No. of persons............................ Showers Cafeteria Otherfixtures ............................................................................................................................... Design Flow.............J T5' ...............................gallons per person per day. Total daily flow.......3-3 ............g-,dlons. P4 Septic Tank—Liquid capacity/00 .gallons Length...4�.*...... Width.....4....... Diameter................ Depth_14......... Disposal Trench—No. .................... Width......_............. Total Length.................... Total leaching area....................sq. f t. Seepage Pit No..................... Diameter...62........... Depth below inlet.......6.... Total leaching areaA4.?.jLsqft.G. Z Other Distribution box (V) Dosing tank ( ) ' Percolation Test Results Performed by.....!�:0 10.....4(....."J 5 4--C Date.A::..Z;��.-84........ t Test Pit N61_1 .. -_-minutes per inch Depth of Test Pit... Depth to ground watenjt��qr. ....C-AJ J- Oi ------- Test Pit Nd.-2................minutes per inch Depth of Test Pit...._:...:..._...... Depth to ground waterdoo,�J_rc_&e I> .............. . ............................................... ............................................................................................................. 0 Description of Soil............................ 4-14 k) ............................................................................................................................................ ......................I.................................................................................................................................................................................... .........................7............................................................................................................................................................................. 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 TITS 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed_.__... ........ ------------------- I-— ------------- - --- ---- ------- te wo-----------&VtLn----------------------------- Application Approved By............**p q. .. '#!te I Application Disapproved for the Ulowing reasons:...........................I.................................................................................... ......................................................................................................................................................................................................... Permit No.... S..-­714.................. IspUcd............................... .........D..a.t..e... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF.:................................................................................... Trrtifiratr of Tantphatta THIS IS TO C IF*T 1Y That th i v Indii I lidual Sewage Disposal System constructed O or Repaired by..................... ..................................................................:;................................................ '6 Instal at...................... 4...........7.................................................................................n......C __P­Q has been installed in accordance with the provisions of TITLE 5 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........... ..... ... .... Inspecto r .......................——————---—————————————---— THE COMMONWEALTH OF MASSACHUSETTS BOARD/PF HEALTH . ............ .....OF.._/Ae ................................... FEE... atoposal luji,rb (11111 r ion pernfit 0 Permission is hereby granted............ ..... ------ . ...................... ............................................ M� V'-Af to Construct or air an In ivi( �cw' ge Disposal Syst atNo....... ................................ . ..... ...... -----------------------------------7-------------------------------- Street as shown on the application for Disposal Works Construction Permit No ----- ---------- Dabcd--------- ........... .............. -------- - 4FDATE----------------- ------- ----------7­...................... T�1P OF' F4t.'NtJ t EL I I O.xq Ito - - - - ----- --- _ . - - 1 v3 nb --T�Z , BOY -._ rig. IQM GALi -- - --- - ---- -- ------ - ---- --------- - ------ - - - -- — - -- - - - _ 0 2 -I TANk r� --- - - u� 41—WA5RED 5T ?4k--, a4i — -� ----- -- - -- - - - - _---- --- -------- ---------- -- --- ---- --- _ -_ _ T& — ------ e x/5ty/-)9 9r0or-7 pr-o¢% l e ----_-_ -- -- ---- EXTC—A.:"D FL L F-3 PPLICf-� t3(_E 0 osed rovnc/ roflle HDi2/�- SCHLE- : / = IO /+ / / ' JA-10 F- G© ✓�,eS TO !nJ/TH/AJ (G � � ! � /�./ li� � dE' 7- S C i9 C..� / _ �O I /2" OF FIAJISf-lED GIcA ��� . t1 SCA4E-D. 40 P v. 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