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CERTIFICATE OF ANALYSIS
Barnstable County Health Laboratory
-
`�'S�Ct{15�,r
Report Dated: 8/14/2006
Report Prepared For:
Order No.: G0637603
William Fenney
2071 Main Street
West Barnstable, MA 02668
Laboratory ID#: 063/603-01 Description: Water-Drinking Water �i„fvk
Sample#: Sampling Location r2071 Main St.W'6'arnstable;MA—'� Collected: 8/10/2006
L_ _ __
Collected by: W.Fenney Before Received: 8/10/2006
Routine
ITEM RESULT UNITS RL MCL Method# Tested
LAB: Inorganics
Nitrate as Nitrogen 0.25 mg/L 0.10 10 EPA 300.0 8/10/2006
LAB: Metals
Copper BRL mg/L 0.10 1.3 SM 3111 B 8/14/2006
Iron BRL mg/L 0.10 0.3 SM 3111 B 8/14/2006
Sodium 14 mg/L 1.0 20 SM 3111 B 8/14/2006.
LAB: Microbiology
Total Coliform Absent P/A 0 0 309 8/10/2006
LAB: Physical Chemistry
Conductance 110 umohs/cm 2.0 EPA 120.1 8/10/2006
pH 6.6 pH-units 0 EPA 150.1 8/10/2006
Water sample meets the recommended limits for drinking water of all the above tested parameters.
co
r
I 1
f
RL = Reporting Limit
MCL=Maximum Contaminant Level
Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605
}� 7M Page: 2
CERTIFICATE OF ANALYSIS
Barnstable County Health Laboratory
Report Dated: 8/14/2006
Report Prepared For:
Order No.: G0637603
William Fenney
2071 Main Street
West Barnstable, MA 02668
Laboratory ID#: 0637603-02 Description: Water-Drinking Water
Sample#: Sampling Location 2071 Main St.W.Barnstable,MA Collected: 8/10/2006
Collected by: W.Fenney After Received: 8/10/2006
4
Routine
ITEM RESULT UNITS RL MCL Method# Tested
LAB: Inorganics
Nitrate as Nitrogen BRL mg/L 0.10 10 EPA 300.0 8/10/2006
LAB: Metals
Copper BRL mg/L 0.10 1.3 SM 3111B 8/14/2006
Iron BRL mg/L 0.10 0.3 SM 3111B 8/14/2006
Sodium 2.1 mg/L 1.0 20 SM 311113 8/14/2006
LAB: Microbiology
Total Coliform Absent P/A 0 0 309 8/10/2006
LAB: Physical Chemistry
Conductance 22 umohs/cm 2.0 EPA 120.1 8/10/2006
pH 6.6 pH-units 0 EPA 150.1 8/10/2006
Water sample meets the recommended limits for drinking water of all the above tested parameters.
Approved By.
(La irector)
RL = Reporting Limit
MCL=Maximum Contaminant Level
Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605
i
TOWN OF B`.• NSTABLE
C'vC;ATION o !//y/) SEWAGE #
`126_AGE m U00 ASS_S qR'S MAP &LOTQ�
-=:NAME&PHONE NO. J 10 _ �(Y��-
SEPTIC TANK CAPACITY l S-0 d ad
;_�—
cL/�}T
LEACHING FACILITY: (ty !size)
NO.OF BEDROOMS
BUILDER OWNER '.7
��.
PERMITDATE: 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) A1119 Feet
Edge of Wetland and Leaching Facili (If any wetlands exist
within 300 of 1 c 'n faci ,Z / Feet
y Furnished b • C•
� N
i
N
W
y
A
�!CP 076 CO A.
� 0
• y'- ,BORTOLOT'rI CONSTRUCTION,INC. APR 2 9 199
765 WAKEBY ROAD,MARSTONS MILLS,MA 02648 tl �
SU8-771-9399 . SU8-428-892f► FAX: 508-428-9399 " En
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 41)7
Date of Inspection c - Inspector's lame:
Owner's Name and Address: f
R
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 ivas per=
formed b on'my training and experience in the proper function and maintenance of on-site sewage
disposal stems. The System:'
Passes
Conditionally Passes
Needs-,Further Eyfluation B (be Local Aproving Authority
Fails
Inspector's Signature: Date:__
The System Inspector shall submit copy of this inspection report to'tlie 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 IMMARY•
A)SYS M PASSES:
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.
B)SYSTEM,CONDITIONALLY PASSES;
One or more system
compone
nts
is ne
ed to be re
Pl aced or rep
aired.afire d. Th
e system up
on comple-
ion-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 wiry 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- W.
,;.> tic.tank:is replaced with a conforming septic tank as approved by The Board Hof 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 -
^ A
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;`mspeetion if,(with approval of The Board of Health):
�13.roken.pipe(s);are-replaced
Obstruction`isi 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
rrthe systerri is failing to protect the public health, safety and the environment.
1)SYSTEM WILL;PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE
SYSTEM=ISNOT 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 systemhas a septic tank and-soil absorption system and is within±l00;Feetto a surface
-water supply or tributary to a surface water supply.
The system has aseptic tank and soil absorption system and is with a Zone I of a public 41,"}
S
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 aseptic 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'frorim`pollution from
' the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than,5 ppm•
D)SYSTEM FAILS:
I have determined that the system violates one or more of the following failure criteria as defined r
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. r.
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'`�` 4
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 NDJ due to clogged or obstructed
pipe(s).,Number of times pumped
-2- d
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 a Zone I of a public well. '
Any portion of a cesspool or privy is within 50 Feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 Feet but greater than 50 Feet from a private
water supply well'With no acceptable water'qualityanhlysis. If the well has been analyzed
-
to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic
compounds,ammonia nitrogen and nitrate nitrogen. ,
E)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 gpd or greater(Large System)and the system is a significant
threat to public health and safety and the environment because one or more of the following:
conditions exist:
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
a F ;
(IWPA).or a mapped Zone I1.of a public water supply well.
The owner or operator of any-such system shall bring the system and facility Wd 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 the following havebeen done:
I __ Pumping information was requested of the owner,'occupant,and Board of Health.:"
!--None 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 Veen
introduced into the system recently or as part of this inspection. -
-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.
_Iffhe system does not receive non-sanitary or industrial waste flow. t'
yi`he site was,inspected for signs of breakout.
✓l system components,excluding the Soil Absorption System,have been located on site
�1`Ite septic`tank manholes" re uncovered,,opened,and the interior of the septic tank wasin1
spected for condition of baffles or tees, material of construction,-dimensions,depth liquid;
Aopth of sludge,depth of scum. •: , v ;
/The iize 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 front owner were provided with information on
( p )
the proper maintenance of Subsurface Disposal System n
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
FLOW CONDITIONS
RFSTD
Design Flow: allons Numbefof Bedrooms: Number of Current.Residents:
Garbage Grinder: Laundry Connected'1'o System:��cS Seasonal Use:_1116
WatgMeter Readings,if Table:
LMt,Date of Occupancy:
COMMERCLALIINDiISTRIAI,o .
Type of Establishment:
Design Flow: . ° gallons/day, Grease Trap Present:,(yes or no)
IndustrialWaste 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
PUMPING RECORDS and source of inform at' n:/)l�lue'^Yam �cW4,2
System Pumped as part of inspection:A, — If yes,volume um 'p ped: gallons
Reasomfor•pumping: ;a
MEWS, YSTTEM Eft, —, .
Septic, ank/Distribution Bo4Soil Absorption System
Single Cesspool
,Overflow,.Cesspool
Privy
Shared System(If yes,attach,previous inspection records, if any)
Other(explain):
r
PROXIMATE,AGE of all components,date installed(if known)and source of information:
Sewage odors detecte hen arriving at the site:
-4-
Y
SUBSURFACE SEWAGE DISPOSAL`SYSTEM INSPECTION FORM
PART C
GENERAL INFORMATION (continued)
SEPTIC TANK:
Y .
Depth below grade: Material of Construction: ✓concrete metal FRP Other '.`
(explain)
Dimisions:_I.P. Sludge Depth: L!5-// Scum Thickness: l a
Distance from top of sludge to bottom of outlet tee or baffle: � 3 `
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.liqui6/47
level in relation to utlet inve�ructural integnt ,evidence of leakage,etc: 5 ''Q /
W; -7�
b �P {
GREASETRAP•
Depth Below Grade:
de:
Material
al 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: gallons/day r,
Alarm Level:
Comments: (condition of inlet tee,condition of alarm and float switches,etc.) `
711,
DISTRIBUTION BOX:_
Depth of liquid level above outlet invert:.
Comments: (not el and distribution is evidence of solid carryover evidence f leakage into
or o t of box,etc p/ yj
PUMP CHAMBER:
Pump is in working order:
Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.)
-5-
; ..,, k
a
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
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:
S
Type: ♦ Y 1
Leachingspits,number.: Leaching chambers, number: Leaching galleries,number; _
LeacKng trenches,,number,length: ,T;
-Leaching fields,�number,.,dimensions: �
Overtlaw'cesspool,number
;Comments:-(note,condition of soil,signs of hydraulic failure.level of po ding,condition of egetation,
etc
CESSPOOLS:Ad
Numberand;configuration: Depth-top of liquid to inlet invert:
Depth of solids layer: Depth of scum layer: Dimensions,of Cesspool: ,
Materials of construction: Indication of groundwater:
Inflow(cesspool must be pumped as part of inspection)
Comments: (note condition of soilk, signs of hydraulic failure, level of ponding,condition of vegetation,
etc.) _
PRIVY: l
Materia s of construction: Dimensions:
Depth of Solids:
Comments: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,
etc.)
4
%
f
-6 -
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include ties to atleast two permanent references, landmarks or benchmarks.-
Locate all wells within 100 Feet.
DEPTH TO GROUNDWATER:
Depth to groundwater: /y Feet ,
Method of Deteriwnation or Approximation:
O 170 /- !Peel 15!l 'W
�r <s
-7-
�,. TOWN OIL BARNSTABLE
`LOCATION�(} �/ �,� rn� 577
SEWAGE
VILLAGE Z309 S'7'e ASSESSOR'S MAP & LOT
�i -
INSTALLER'S NAME & PHONE NO.Aa L Y J
SEPTIC TANK CAPACITY
LEACHING FACILITY:(typeC6)6411,v (size)3.2 oc _
Yo`C 1AC 61
NO. OF BEDROOMS S PRIVATE WELL OR PUBLIC WATER Pu
F
BUILDER OR OWNER «���/� n, �C' /t//✓ J
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED k
VARIANCE GRANTED: Yes No__
� �
I
V
�� _�_;_�_�_-1-.
l � .I! N�.
f '� 1
1.
,_R• g F .,
No.��s.s.. c . i 'm - _� Fizs.....�.....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
-...Q:.wG+.................OF........
Appliratiuu for Eliupuuttl Works Tomitrurtiu amit
Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal
S tem at: S,,,
.................-----����, . /. ... ............................. ..... ..-------- ............ ..........................................
Locatio •Ad.dres or Lot No..
.................... . ..... �!k N,�� ' .... : : � .....fi...1 -��¢} --...........
2 G. caner ,.' Address
W ....:'''.--�... •-••---•-----•.................................
a ------ ..........._
Installer Address
Type of Building )qzSize Lot............................Sq. feet
U Dwelling—No. of Bedrooms....... ... . ........ / .....Expansion Attic ( ) Garbage Grinder
Other—Type of Building No. of persons............................ Showers — Cafeteria
p' Other fixtures ..................................
Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
W.W Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No. .................... Width-------............. Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No.•------- ----------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
'-� Percolation Test Results Performed by.......................................................................... Date-----------------...................---.
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
L� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a •-••---------•-----------------------••-------------•----------........................--•--------•..........................................................
0 Description of Soil............................................................-•-•-•-•----------•---•-•---•------------•-••--........-•--------------......._......_........_----•------...
W
V .....•-•-••••-•-•----•--•-••-----••----------------------------••-•--•----------------------------•--.....-------•-••----------••---------•----------•--•---•-----•-•-------•-----....--------...----•---
W --•----------------------.............
UNature of/Repairs or Alterations—Answer when applicable-. _ ._�.�............_�_�._�_o " �`�
�✓ ............------may s/-.................•---...-----------------••------------••-------•---•------•--•-----
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITi U 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has be issu y the bo rd of h
Sign ............. .......................... ...............
Application Approved ...... -•---•• ..... ....................................... D e
--_- ate
Application Disapproved for the following reasons:..............................................................................................................
-
.....................•••---...._.....................•-••-•----•-........--•--•........_.._............--••------.............._...--•-•-----•-•-•--••------•----•••---.....--•-•----•-•--•--------•----
^^ Date
_�^^
Permit No.............................................�-.-�-J•-v------ Issued.---------•----------------------•-•--------------------
Date
CD-
No... Fis.......
�
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF EALTH
-- 7ntr
OF.................................�S.I_.� :�................
Applirtttion for Dispoiittl Works Tianstrurtiort rtrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
......... ....----------------------.........--------. ............_.. ................
Lon Address ...........-•-----••-•....................or Lot No.
..:..........�.._ � _....r.--1�,. .. ...................................... ..-----...............................................
` � er Address
Installer Address
UType of Building Size Lot............................Sq. feet
�.. Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
'4 Other—Type T e of Building No. of persons........................ Showers
� yP g ---------------•---------... p --•- ( ) — Cafeteria ( )
QOther fixtures .............•----•----------------.......-•-•------........--•--•---••-•-----•-•--•--•---------•-•---...............----...........---•••---•-.-----•
W.
Design Flow............................................gallons per person per day. Total daily flow............................................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....-_....:........ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by--•--•-------•---•-_..................................................... Date........................................
4
Test Pit No. I................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........................
--••-------------------------•--•---.......-•---•-•----•--•--•-----•----•......••-•-----......•••............................................................
0 Description of Soil........................................................................................................................................................................
x
c, •--.........•••---•---••--•-----•----••----•---•..................................•-•••-•------............-----._...........-----•-•--••-•--- . ..------...........--•---•-••---••.........._...----
w _ _
U Nature of Repairs or Alteratio n whe�appli � � �.....LP:-1-C?�......t��_.........
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System.in accordance with
the provisions of TITIS 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.
---------------------------- 4ae-
ApplicationApproved By.................................................................................................. ........................................
Date
Application Disapproved for the following reasons:..........................................................................................................
----
--...----••----•----•........................... � .2 Date
-•--•--••••--•...........•----•-••••------...------••••-----••-........................-_... ............»
PermitNo......................................................... Issued_.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD QF,..&JFqNLTH
..........................................OF.....................................................................................
Trrtif irtttt of flonmplittnrt
THIS IA TO CEI?TIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by................ ...................-•••-------•---•--------
•--•--• ----- •------•••••---•----.:_....•---.................................--••-............ ......_
1
at................. .� _..c......_.. �5�. s
has been installed in accordance with the provisions of TI��S of:'h'e�ate Sanitary Cc __] ' �es(rk 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........................ - 5 .............................. Inspector..........................
- ........................................
A-- 'Z i& - 3 THE COMMONWEALTH OF MASSACHUSETTS
(- � BOARD HTH
2.0D ...........................................0F.....................................................................................
No......................... Fn........................
3�i��oott or � �on�#r�rtion �rrmit
Permission is hereby granted.......... ... . C:.... .....
to Construct ("7�oRepair ( ) an Individual a e Dis osal System
S reet
as shown on the application for Disposal Works Construction Perrrut
_ .....
- _
DATE Board of Healthy
.
�f 1.
�1 1.
5;
FORM I 5'�3,,,,.A• M- SULKIN, INC., BOSTON
�.
1
e; -tN6 - —
o
660 "t_ reE-c%T t-A r
t2WEwAY
EKSGTIM& LE+�c1n. FLE(.� �gPf'Rpc LCc�at�gN�
c�
a n
oov
.DLO CATION E A G E PE RMI NO.
2071 1 �, ��- GAS
VILLAGE
e—Em � c
INSTALLER'S NAME i A. DRESS
Is UI.LDER OR OWNER
n
DATE PERMIT ISS ED t
DATE COMPLIANCE ' ISSUED
� G
Z
V1
fi
m
PT
VAR. , T49WEALTIJ DE
Town ,Ofice Bulldin'g
60
No.3 Swith _Wniac Ah, JVIA 02,fal FEz......b-::.. .....-
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF. HEALTH
..........................................OF...:. .(N... . ........................................
Appliration for Disposal Marks 6uskurtion Frim' d
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at:
.......Sr\47AA&�.....trk-kls............................................ ........62..Q:2.1.......1
Locat.on-Address ------ or Lot No.
V.... ner
OW �f4.
......................�5__ ... ------------*--------------------------- ---------- ................... ....... ..... ...............................................
Address
a- ....................... . ........
Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms................7-----------------......Expansion Attic Garbage Grinder ( )
Other—' Type of Building ............................. No., of persons............................ Showers Cafeteria ( )
Otherfi t ......xt!!.rw ------------------------------------------------------------------------------------------------------------------------------------------------
Design Flow......... .....................gallons per person per day. Total daily flow. ................gallons.
Septic Tank—Liquid capacity.......:....gallons Length................ Width................ Diameter................ Depth................
Disposal Trench—No..................... Width--.:............._._ Total Length..................... Total leaching'area....................sq. ft.
Seepage Pit No...................... Diameter.°.................. Depth below inlet.................... Total leaching area..................sq. ft.
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.....I...................
-Test Pit No. 2................minutes per inch Depth of Test. Pit.................... Depth to ground water........................
--------------------:............................................................................................................ . .....
Description of Soil...... jr.�, , an __95_( .-i�. ...... ......Ck).A!��._BJ6.L...............
--- ------------A
.................................. t..- .
I....................................................
...................................................................................................................................... ....... ........Z�. .....................• .
41
U Nature of Repairs or Alterations—Answer when applicable........I . ....... . ---
---- --Wnl
............................................... . ........................... .............................................................. .............................
Agreement:
. The undersigned, agrees to install-the- aforedescribed Individual Sewage Disposal System in,accordance with
the provisions of'L 1'L LZ 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Complianc by the oa
n ..... ..... .... ....... ---------- ... =�_kn=ac5.
Date
Application Approved By................ .... .......................I............I......... D
7- ......................ate..................
Application Disapproved for the f l m6ing reasons:.............................................a....... .....................................................
..................................................................................................................................................................................... ..................
Date
... .....Permit No... ...................... .......... .. ...... Issued........................................................
Date
Fxs.... ! :..b
THE COMMONWEALTH OF MASSACHUSETTS .
BOARD OF HEALTH
................................OF.......�. •t( ti��`t?...._..........._..---..............
App irtt#iun for Dispusttt Marko Tonstrnr#iun Frrnti#
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an' Individual Sewage Disposal
System at
...... \t EJA i c.................. ....................... •-•-- o`er c...
Location-Address or Lot No.
..................... � :w.� s:-.............._......---•-
\'/' Owner ��—',',':,> k ,y Address.'
.......................................iC ... ✓ 1�.............................................: L .......c vG_ < - � ►v L 4 1 c........ 9 / ..............
i
.....
Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms................ .........................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No. of persons................. Showers —
f� YP g ---------------•------------ P ....--•- - ( ) Cafeteria ( ) 1
PaOther fixtures .•--_.... ---------••--•--••-•--•-•---•----•---•-•-............................................................
Desi Flow. -''S ................ .. allons er erson er da Total dail flow.....-~�. _....._ . Ions. i
W gn ,. d g P P P Y Y C :
Disposal Trench tic Tank—LiquidNocapacity.......WidthnS.....Lengt Total'Leng Length
................Total leaching area.._Depth.------sq. ft. fit;
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by........................... ......._........... Date..................
aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Test Pit.No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a •-•-•--------------------•--------------------......-------•---....---....•..---.................................----:...-------. ..........._.
O Description of Soil..........._2 r�..�. c-'-�AA----� .... L.cr,!�. Q ---- R
1 w Ya 25 ✓S 1A-CQ G�
(�j .... ...................... ....... •--•---•----------......•---....----
x --------------•------....-•----...------•----------------•-•--•-•------•---..............----------•-----------...------------•--------------.........-•------..........................---'--.....
U Nature of Repairs or Alterations—Answer when applicable--------c�_D.D...... -.....
-- = =
Agreement: i
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions Iof T ITIE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has-been issue by the oa f-health.
i s.
Date
Application Approved•BYE --- ------------------•- --•-----
ti....•l. ' ' Date,
Application Disapproved for the f 1 owing reasons-........................................................ -...---------...---•------•-_... ---------•--
••-•-•• ----------•-•--•--......--•.---- ---•--. --=--•-•••---•--•--•-•----------••-.................... ••... -•---•-•----..._...............--•..... .•••....._
Dati'
PermitNo....................................................... Issued-...............................
Date
,. THE COMMONWEALTH OF MASSACHUSETTS vy Jb-j J\,A
BOARD OF HEALTH
..................... .........OF............................................... ................................
f�pr#if utt�e laf f�,ant�li�tnrr
THIS ISS' TO CERTIFY, ha the ndividual Sewage Disposal System constructed ( ) .or Repaired { )
by... •••-- .......4.. ------ -=--- -- ......................... -. ...................................................
` Instal er
at................ �......---• ---------��-_ .-•I�t J ............. .... .. .V... ............-....
has been installed in accordance witli the provisions of TITLE 5 of The State Sanitary Code as e•cr'bed in the
application for Disposal Works Construction Permit No.-g_S_._:_4�.5... ........... dated__...._." - -- --- -- -__----..---------.-
® AS A OUA�A T E THAT THE
THE .ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CO�STRUEP
SYSTEM WILL F NCTIO . SATISFACTORY.
DATE.. •-•------------•--•. Inspector....- = -t.. -� � �
/ t"THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF �a` Ls ' f
No....��— CYI ........
..... FEE.. .......
v� t J i`.
Permission is hereby granted_... ---- ...�.��.�.........................................................
;t � .....
to Construct ( ) or Repair ( ) an Individ Sear posal System
atNo. * ' --..D.D_1.._J; ... 1\ ---------•------•---•-•-----••----•------------------------..........................
t.. (Ani .f Street G
ras shown on the application for Disposal Works Construction Permit NO. _- �.._----
.l.Z_. ....
.................................. ..-----•......••---•----•-----------•-............................_
_.. � Board of Health
DATE.............. �--- ----•-------------•-