HomeMy WebLinkAbout3695 MAIN ST./RTE 6A(BARN.) - Health 3695 Main Street/Route 6A, Barnstable
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET. BOSTON. MA 02108 617.292.5500
W1LLIASI F N ELD
TRL D1 CO
GoNcmor Sc:rc:
ARGEO PALL CELLUCCI D.A�ID B STRL
Lt Govcmor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Cornrnissic
PART A
CERTIFICATION
/s'I AIN 5T/! ,OUYf, 64
Property Address: 3 69 5 Route 6A Barnstable,Mass. Address of Owner: BOX 97
Date of Inspection: 9/8/9 7 (If different) Barnstable,Mass .
Name of Inspector: Joseph P. Macomber Jr . 02630
1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: Joseph P. Macomber & Son,_ nc .
Mailing Address: oX Centerville Ma • 0�32-0066
Telephone Number:CERTIFICATION STATEMENT
I cenrly 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 funcllon ano
maintenance of on-site se age disposal systems. The system:
Passes /
Conditionally Passes
N—A, F..nhar Fvahiarinn Rv tha I oral Annrnvin¢ Authority
Inspector's Signature: = 9 9 7
The Sys(em Inspector kaAllw"L
bmit a.copy of this inspection repport to the Approving Authoriitty 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 ovmer shall sunmo
the repon to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the sys7em owns
and copies sent to the buyer, if applicable, and the approving authority.
INSPECTION SUMMARY: Check A, B, C, Or D:
A) SYSTEM PASSES:
.1l have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15 303
Any failure criteria not evaluated are indicated below.
COMMENTS:
BJ SYSTEM CONDITIONALLY PASSES:
One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upo
completion of the replacement or repair, as approved by the Board of Health, will pass.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain wh•, no(
j� The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Cenjfica(e of
��-- Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection. c
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or cant
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
(revised 04/25/97) Page 1 of 10
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 3695 Route 6A Barnstable Ma
Owner: Rick Lamb
Date of Inspection: 9/8/9 7
B) SYSTEM CONDITIONALLY PASSES (continued)
1iL4r>✓ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the
Board of Health). Describe observations:
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
_O 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:
,Q Cesspool or privy is within 50 feet of a surface water
y� 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 FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
,X The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or
tributary to a surface water supply.
The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
Alf) The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that
the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method used to determine distance (approximation not valid).
3) OTHER
(revlsod 04/25/97) Pap• 2 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:3695 Route 6A Barnstable Ma
Owner: Rick Lamb
Date of Inspection: 9/8/9 7
D) SYSTEM FAILS:
You must indicate ewer "Yes" or "No" as to each of the following:
AJ0 I have determined that the system violates one or more of the following failure criteria as defined in 310 CN1R 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.
Yes No
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume is less than 112 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped _
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
�J Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
�) Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to.be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
EJ LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No" as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
N(/ . The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area - IWPA) or a mapped Zone 11 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.
(revised 04/25/97) Page 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 3695 Route 6A Barnstable Ma
Owner: Rick Lamb
Date of Inspection: 9/g/9 7
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
Pumping information was provided by the owner occupant, or Board of Health.
None of the system components have been pumped for at least two weeks and the system has been receiving normal
flow rates during that period. Large volumes of water have not been introduced into the system recently or
as part of this inspection.
As built plans have been obtained and examined. Note if they are not available with N/A.
The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non sanitary or industrial a waste flow.
The site was inspected for signs of breakout.
_ All system components, eluding the Soil Absorption System, have been located on the site.
_ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of
baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
/ —The size and location of the Soil Absorption System on the site has been determined based on:
1/ The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal System.
Existing information. Ex. Plan at B.O.H.
_ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) [15.302(3)(b)]
(revised 04/25/97) Page 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:3695 Route 6A Barnstable Ma
Owner: Rick Lamb
Date of Inspection: 9/8/9 7
FLOW CONDITIONS
RESIDENTIAL:
Design flow: ? ?,.p.d./bedroom for S.A.S.
Number of bedrooms:
Number of current residents:
Garbage grinder (yes or no): L::*
Laundry connected to system (yes or no):L--S—
Seasonal use (yes or no):zs ��j /
Water meter readings, if available (last two (2) year usage (gpd): 1,/'g-V ✓�_ / el
Sump Pump (yes or no):1f1V 6`� fC/1G�5 :yam i
vev 1ou� �e ,e 1, 7-
Last date of occupancy: L� � �"
COMMERCIAUINDUSTRIAL:
Type of establishment: A/
Design flow: 4)# gallons/day
Grease trap present: (yes or no)A2
industrial Waste Holding Tank present: (yes or no)LI-4—
Non sanitary waste discharged to the Title 5 system: (yes or no)&�
Water meter readings, if available:lf A
)Ljkq
Last date of occupancy:
OTHER: (Describe) A2 4
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as part of inspection: (yes or no)
If yes, volume pumped: gallons
Reason for pumping:
TYPE O�YSTEM
{j Septic tank/die+.—fjox/soil absorption system
7— Single cesspool
— Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
lt4 I/A Technology etc. Copy of up to date contract?
Other
�J
APPROXIMATE AGE of all components, date installed (if known) and source of information:
Sewage odors detected when arriving at the site: (yes or no)
I
(revised 04/25/97) Page 5 of 10
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 3695 Route 6A Barnstable Ma
Owner: Rick Lamb
Date of Inspection: 9/8/9 7
BUILDING SEWER:
(Locate on site plan)
Depth below grade:
Material of o struclion: cast iro 40 PVC other explain)
`3v .0, L_ �jroTa C�r�x���f *
Distance from private water supply well or suction line w-)/4,
Diameter yt1
Comments: (condition of joints venting, evidence of leakage, etc.
-v T-AVr o[4
SEPTIC TANK:�U� �S
(locate on site plan)
G"Depth below grader
Material of construction: concrete _metal _Fiberglass _Polyethylene _other(explain)
If tank is metal, list age &A Is age confirmed by Certificate of Compliance V (Yes/No)
Dimensions: 0 �I'kceo //,1G����1�U 6�7"
Sludge depth:
Distance from to of sludge to bottom of outlet tee or baffle:
Scum thickness: ,T7, GL _
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
How dimensions were determined:
Comments:
(recommendation for pumping, condit n of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of le kage, etc.) % —3 T
GREASE TRAP:,
(locate-on site plan)
Depth below grade:w/�
Material of construction:U/9 concrete.U�metal�/FiberglasA/A PolyethyleneilJfi'other(explain)
/9
Dimensions:
Scum thickness: IVA
Distance from top of scum to top of outlet tee or baffle: 411*
Distance from bottom of scym to bottom of outlet tee or baffle:A0/g
Date of last pumping: A)7_
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.)
rv-4sle ra42
(revised 04/25/97) Page 6 of 10
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Properly Address: 3695 Route 6A Barnstable Ma
Owner: Rick Lamb
Date of Inspection: 9/8/9 7
TIGHT OR HOLDING TANK:/ F1 Jank must be pumped prior to, or at time, of inspection)
(locate on site plan)
Depth below grade: 4111
Material of con struction:4/A concrete/LAmetal4U_}lFiberglass44,41"olyethyleneVother(explain)
AM
AM
Dimensions: :VA
Capacity: )lam gallons
Design flow:A_ gallons/day
Alarm level:�� Alarm in working order M Yes;, {A No
Date of previous pumping: AJA
Comments.
(condition of inlet tee, condition of alarm and float sv itches, etc.)
DISTRIBUTION BOX:/d/M/e-
(locate on site plan)
Depth of liquid level above outlet inven: AW
Comments:
(note if level and distribution is equal, evidence of solids carryover, evviidd`en-cye—of leakage into or out of box, etc.)
PUMP CHAMBERAZ�Vc_
(locate on site plan)
Pumps in working order: (Yes or No)
Alarms in working order (Yes or No)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(r.evimed 01/25/97) Page 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Properly Address:3695 Route 6A Barnstable Ma
Owner: Rick Lamb
Date of Inspection: 9/8/9 7
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:_
leaching chambers, number:
leaching galleries, number:=
leaching trenches, number,length: (�
leaching fields, number, dimensions:
overflow cesspool, number
Alternative system:
Name of Technology:
Comments:
(not?priclition f $oil, si ns of ydrautic fail re, level of po ding, condition of vege anon, et .)
1 r
CESSPOOL
(locate on site plan)
Number and 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: idJUAC
inflow (cesspool must be pumped as part of inspection)
C5 VP V 1
Comments:
(n e con ition of oil, si ns of hydraulic failure, level of ponding, condition of ve elation, et .)
j9
PRIVY:
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:_.
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(
(revised 04/25/97) Page 6 of 10
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Properiy Address: 3695 Route 6A Barnstable Ma
Owner: Rick Lamb
Date of Inspection: 9/8/9 7
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
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/ D
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�C 7 of 109 7 6 A
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:3695 Route 6A Barnstable Ma
Owner: Rick Lamb
Date of Inspection: 9/8/9 7
t
Depth to Groundwater . Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observation of Site (Abuning property, observation hole, basement sump etc.)
Determine it from local conditions
_ZCheck with local Board of health
Check FEMA maps
_heck pumping records
heck local excavators, installers
Use USGS Data
Describe in your own words how you P�tablished the High Groundwater Elevation (Must be comnlotod'
pE
ria.%1si�i.1C�s; ���`�rc i, )ri;4-•� '��5,�'I°L'1. (=�/U7"GL(yj
(r.vis.d 04/25/97) Page 10 of 10
(- r-.�.r+-n .T Tr.T�_ .•T.lY�:T T n:•.lr.`.'•.f:A'.-RTT1 TT.".L.'."•"�."."..•..T RTL-•a-.^cTl"II T'r�-•-.- r.--r- - ._
'I'OHN OF Barnstable WARD OF HEALTH
SUNSUNFACF, SF.KAGF, DISPOSAL ,SYSTEM 1NSPFCTION FORM - PART U CF.ItTI FICnTIO
�� �...-...t.....r-�.t '.��T.t•.�n•rt:*TTT:RTIT'T•TP'1'.r-•.1^1ITT\RT�r"�.fT RmI•'•mm�tl-iTrrr�.-rr•.-• r--.- -.
-TYPE OR PRINT CI.EARL1'-
PROPERTY INSPECTED
STREET ADDRESS 3695 Route 6A Barnstable,Mass .
ASSESSORS MAP , BLOCK AND PARCEL #
OWNER ' S NAME Rick Lamb .
.� PART D — CERTIFICATION
NAME OF INSPECTOR Joseph P . Macomber Jr .
COMPANY NAME Joseph P . Macomber & 'Son , Inc .
COMPANY ADDRESS Box 66 Centerville , Ma . 02632-0066
5tr99t To✓n or Clty 5tat. tip
COMPANY TELEPHONE (508 I 775 -3338 FAX ( 508 ) 790 -1 578
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposa-1 system A �
this nddress and that the information reported is true , accurate , and
complete as of the time of .-inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems ,
Check one :
CXXXXX XXXXSystesi PASSED
The inspection tlhich 1 have conducted has not found any information
which indicates that the system fails to adequately protect public
health or the environment as defined in 310 CMR 15 . 303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form ,
System FAILED4
The inspection which I have con kicted has found that the system fails .c
protect the public health and the environment in accordance with Title
5 , 3tO CMR 15 . 303 , and as specifically noted on PART C - FAILURE
C:[tITERIA of this inspection form .
,Inspector Signature Date9/9/97
One copy of this certification must be provided to the OWNER , the BUYER
( where applicable ) and the DOARD OF 111iAL7'll .
If the inspection FAILED , the owner or"'oporator shall upgrade the eyotem
- it.hin one year of the date of the inspection , unless allowed or require(:
otherwise as provided in 310 CHR 16 , 305 .
partd • dcc
w
P7
THE COMMONWEALTH OF MASSACHUSETTS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BE IT KNOWN THAT
Joseph P. Macomber, Jr.
Has satisfied the Department's qualifications as required and is hereby
authorized to use the title
CERTIFIED TITLE S SYSTEM INSPECTOR
as provided in 310 CMR 15.340 and Section 13 of Chapter 21A of the
General Laws. Issued by The Department of Environmental Protection_
Junc s. 1995
Acting Dircctor of the ion of Watcr �PoLlufi�onCo�otrol
TOWN OF BARNSTABLE
LOCA7 ON �G�'� � T �� SEWAGE #
VILLAGE �� � � ASSESSOR'S MAP &LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY /0� "' l��—,0
LEACHING FACILITY: (type).! �S OII%� (size) IWO
NO.OF BEDROOMS
BUILDER OR OWNER Xf�
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 f�1eacWacX,,,,,P;-#, Feet
Furnished b
'r9
a
.01
f
36 `? RT A
TOWN OF BARNSTABLE
LOCATION ley / ' 4144" SEWAGE #
le-
VILLAGE ASSESSOR'S MAP & LOl?j
INSTALLER'S NAME PHONE NO.
SEPTIC TANK CAPACITY ��
LEACHING FACILITY:(type) (size)
NO. OF BEDROOMS y PRIVATE WELL OR PUB90"CATER
BUILDER OR 2NXE'R T—
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCf. GRANTED: Yes No
Gv /fir m
E �
' IL I
70
e •� ... .. �..JCJ F-•—_
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
� e
EL
_t . ......OF..........P.. ..:'.
Apphration -for i_gpmal Vorko C onstrurtion Vrruift
Application is hereby made for'a Permit to Construct ( ) or Repair ( ) an Individual wage Disposal
System at: 3s
--
r� �Loo tion•Address or Lot No. p _ ow
......................(r�S! \e?.. �..•...!5 .s__......_.. D!:R�?l� ..............•--•----
c,.IO�winer �A�/ r�MA��ddr�esss `' .
----•--•-f-- = �.a•+=� •---•-----sku okk -•--- ...-_l.�et F-..._ ....t...4dJC'��G.�17�d:1O.A !-'-----------------•-------------••---
Installer Address
d Type of Building -' Size Lot----------------------------Sq. feet
U Dwelling—No. of Bedrooms----- Expansion Attic ( ) Garbage Grinder ( )
pa., Other—Type of Building ............................ No. of persons..-•._-_._-___.__-:.._----- Showers ( ) — Cafeteria ( )
a Other fixtures _
d ------------------------------------------------------------------------------------------------- ----------------------------------
W Design Flow........... _...._'_P..........gallons per person per day. Total daily flow...._.LPG-.------------------------gallons.
WSeptic Tank—Liquid capacity-_100.4•�gallons Length................ Width-------,_-__-- Diameter_--.-...__-_-__ Depth---._.-_.___-
x Disposal Trench—No. .................... Width___.______________.. Tot, Leength_-______"________--- Total leaching area--------------------sq. ft.
Seepage Pit No......I.............. Diameter..._.__.!_.........repth below inlet.... .___._.._.__.. Tota eacliing are a-._--____---___sq. ft.
z Other Distribution box ( ) Dosing tank ( ) di ti R C I <
~" Percolation Test Results Performed by----------- 40Fe(------------------------------------------- Date------ -7)/_
Test Pit No. 1__'�i_ ---minutes per inch Depth of Pest Pit..... ........... Depth to ground water...--_-_------.-_.-_
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water--._---..__._--_---_.___
lx ........................-.................................................................= --------------------------------------------------------------
0 Description of Soil.................................•----•--••---••-------------------•----------------------------------•----••-•---•--------------------------------------------------
x
V --------------------------------------------------=-----------------------------------------------------------------------------------------------------------------------------------------------------
W
VNature of Repairs or Alterations—Answer when applicable..----------------------------------------------------------------------------------------------
-•---------------------------••-------------------------------------------------------------•----•---------.-----------------------------------•--------.--------.-------••--•.----•---------- =
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary CodeTheundersi ned further agrees not to place the system in
operation until a Certificate of Compliance has been isof eal
'1,4
Date
Application Approved By..
Date
Application Disapproved for the following reasons:----•----------•---------------- -•------•------•--•---_----•-----------•--•--•• ------------------
..............•-......--•....._..._...........__.......---•----•-•-......-••-----•-••---•--•---•---------•----------••----.._---.........----�/' ?
-•--....................................
Date
PermitNo......................................................... Issued..... ••� {�----------••------
to
-------- ----- -'-- - _ -------------------------------------
- -z
.................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O� HEALTH
;J!
O...u! ----OF...........
- 1�.fir .,...:.........
ApV irtttiun -fur Biupuuttl Works Towitrurtiutt Pprinit
Application is hereby made for a Permit to Construct- ( ) or Repair ( ) an Individual` wage Disposal
System at:
�4 1 �'; Z-�?'Si A��---------------------- � �4�1 '� � -. ^.. .K t'bLT,rtI
�LLooe ,ion-Address or Lot No. _
....... _!2 .................................................... ...........inim ........51._--•-•-•--•_M nis�A�`�a3.! !)t�. ----__-____-•-•---
Owner f,ddress
p (1.�j i �p.�,. ��`�/ p k�per- /�y+ }
a .............{- - ""---•----__ II�A: IY:-----------•--•----•----•-------•---•- --•_-!o? .Z' _._6aQ ..-•----r--t A'.. 11!''�l wlc ---...-•-- ...................
p Installer {Address
Type of Building Size Lot----------------------------Sq. feet
Dwelling—No. of Bedrooms-------��___--------------------------------Expansion Attic ( ).� Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons----------------------------> Showers ( ) - Cafeteria ( )
Other fixtures --•---------•---•----------•---- - N
W Design Flow__________________________ ..........gallons per person per day. Total daily,,flow___.____OAP.o_____ _______._.__.---gallons.
WSeptic Tank—Liquid Li uid capacity---tPgQgallons Length................ Width-----.Az.__-. Diameter............I--- Depth._--_._-__.--.-
P q No......-•-•-••-•••---- Wt th------ o Length._..-----T.?!...•-- Total.leaching area--------------------sq. ft.
x Seepage PIt No..... 1 _. e�'�4- rrY`
iosal Trench— .' Diameter..._.___r_.....__._ 'Depth below inlet_____ ____________ Tota eacling area_______.____---___sq. ft.
z Other Distribution box ( ) Dosing tank ( ) Qom! +
aPercolation Test Results Performed b 5f( _j.�.. .............................. Date....... -11 � ___
.'Z,11n Test Pit No. -. minutes per inch Depth of Test Pit-----�' .._.._..__. Depth to ground water.'_._______________
rs, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
DDescription of Soil--...................................................................------------------------------------------------------------------------•---------------------------
---------------------------x
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 Article NI of the State Sanitary Code— The undersigned further,aAees not to place the system in
operation until a Certificate of Compliance has been issued b �*t e+t�oa ofieal
igned .....-••• . ---- '`� ``...............�q-�
�-------------
Dat
Application Approved By......
7 -------------
Date
Application Disapproved for the following reasons--------------------------------- ..............................................................
---------•----------------------•---------------------- ----------------------------------------------------------------------------------------
Date
Permit No......................................................... Issued.----- ���---- --•---•----
�e
tJ
THE=':COMMONWEALTH OF MASSACHUSETTS
f BOARD HEALTH
. . ..............OF.........
�a wrtif irate of 0,11utpliatta
T ISMS. 0 CERTIFY, hat the In vidual Sewage Disposal System constructed ( ) or Repaired
/ Install r
at...`.......R1.44------- - . ...... .....-.....=-- ------ •..- ✓C 'l" ...........................................................
has been installed in accordance with the provisions of Article X�fe State Sanitary od as de ribe in the
application forDisposal Works Construction Permit No.-_ _.•_______- dated.. .. .. ... ..... ................ ;
THE ISSUANCE OF THIS CERTIFICATE SHAD NOT BE CONSTRUED AS GAR PITEE HAT THE
SYSTEM W L FU 7 CTI SAT,SFACTORY. "
DATE
Inspector_"'_ _ya. ....V.v.... .....................................
ry5, TH.E COMMONWEALTH OF MASSACHUSETTS,- '
�t�,• BOARD OF HEA
No .... ........OF........ (-- FE .
DisVutittl or nu iitrttr ivat rr
Permission is hereby grant d--- ___._ ___ __�.. .... ... .. .... " . .... ..... (. !
to Constru t ( ). or Repair ( I divi .Sewage D posal -Sys
at,'No _ 4-c -•--------A-t- . .�7..----. - -- ..
Stree
as shown on the application for Disposal Works.Construction mit No. ... Dated__________________________________________
• �
o r of H
DATE---- ------� ---- -------------------------------------------------
r _
ealth
-Old
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