HomeMy WebLinkAbout1360 MARY DUNN ROAD - Health • 1 Mary Dunn Road
Bamstable
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�No. �z) — 7 Z Fee 50 00
TH (COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
ZIpprication for Migool *pftem Cow6truction Permit
Application for a Permit to Construct( )Repair(X)o Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
r Location Address or Lot No. 1360 Mary Dunn Road Owner's Name,Address and Tel.No. 3 6 2—1 5 3 7
Cummaquid,Mass. 02637 Everett Peters
Assessor's ap/Parcel 3 3y 0 o s— 1 360 Mary Dunn Road Cummaquiq,Mass.
Installer's Name,Address,and Tel.No. 5 0 8—7 7 5—3 3 3 8 Designer's Name,Address and Tel.No. 02637
J.P.Macomber & Son Inc. J.P.Macomber & Son Inc.
Box 66 Centerville,Mass. 02632 Box 66 Centerville,Mass. 02632
Type of Building:
Dwelling XX No.of Bedrooms 5 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 355 GPD gallons per day. Calculated daily flow 3X 1 1 0=3 3 0 GPD gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil Loamy sand to clay base Gana to Medium sand.
Nature of Repairs or Alterations(Ans X when applicable) Adding 500 a 11 o n leaching
chambers
. Th6rp is a split gyste1 hQrg.
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issu-d by this o of Health.
Signed Date 1 1 /2 2/0 0
Application Approved by Date
Application Disapproved for the following reasons f
Permit No.2,='7 23 Date Issued Z 7 ZdVfl
f
TOWN OF BARNSTABLE €
LOCATION i'Sco0 )MA9r OwN.0 SEWAGE #
r+ i
VILLAGE bAQ.iil,))-Abij,— ASSESSOR'S MAP & LOT AA
INSTALLER'S NAME&PHONE NO. _tlaCG rn b� °)Sq
SEPTIC TANK CAPACITY 160y
LEACHING FACILITY: (type) (size)
NO. OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE: (/'✓
Separation Distance Between the: .
Maximum Adjusted Groundwater.Table to the Bottom of Leaching Facility Feet
Private,Water Supply Well and Leaching Facility pp y If an wells exist
8 tY ( Y
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 c"
j
1 is
j
Y Lip C\
jYj���
TOWN OF BARNSTABLE
LOCATION ) :!93:
SEWAGE # /o
VILLAGE ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. _fA6ec--,r.•QED
SEPTIC TANK CAPACITY 1Cno CA 1 ,
LEACHING FACILITY: (type) (size)
NO. OF BEDROOMS
BUILDER OR OWNER
i
PERMITDATE: COMPLIANCE DATE:
1 Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
I 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) Fee
`Furnished by
L.t
-7 �,,,� �w. -. .- 5 0.
No. G'o'v","" �Z� �` �-�= Fee$
THE COMMONWEALTH OF MASSACHUSETTS
Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
010 ication for Miopoml *pgtem Conaruction Permit
Application for a Permit to Construct( )Repair(XX)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 1360 Mary Dunn Road Owner's Name,Address and Tel.No. 3 6 2—1 5 3 7
Cummaquid,Mass. 02637 Everett Peters
Assessor'sMap/Parcel -� 3y oaSi 1360 Mary Dunn Road Cummaquiq,Mass.
Installer's Name,Address,and Tel.No. 5 0 8-7 7 5-3 3 3 8 Designer's Name,Address and Tel.No. 02637
J.P.Macomber & Son Inc. J.P.Macomber & Son Inc.
Box 66 Centerville,Mass. 02632 Box 66 Centerville,Mass. 02632
Type of Building:
DwellingXX No.of Bedrooms 5 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 1 355 GPD gallons per day. Calculated daily flow 3 X 110=3 3 0 GPD gallons.
Plan Date Number of sheets Revision Date
R.
Title
Size of Septic Tank Type of S.A.S.
Description of Soil Loamy sand to clay base sand to medium sand-
Nature of Repairs or Alterations(Answ r when applicable) Adding d 5 0 0 gallon leaching
chambers to an existing'�1000 clallon tank)box andh 000 plt�-
There is a split sysfem hPrP
- Date last inspected:
Agreement: Y=
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this is of Health.
Signed Date 1 1 /2 2/0 0
Application Approved by Date z �
Application Disapproved for the following reasons
Permit No.2'7 2 3 Date Issued �z 7
' THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Comp ia=
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repat'red)f XX)Upgraded( )
Abandoned( )by J.P.Macomber & Son Inc.
at 1 360 Mary Dunn Road Cummaguid,Mass, has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No COZV-�Z I dated /V 7 Zfy-0 .
Installer J.P.Macomber & Son Inc. Designer J, _P.Macomber/& S'bn Inc'. A
I \ �1 /.;tYl O
The issuance o ,this ermit shall not a co strued as a guarantee that the s , .tem wi11 function as designed.
�
Date u/ ) Inspector
t
Z 3 ---------------------------� 50. -
00
No. Fee
3 y 00 THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
` 30iopooal 6potem Co'notruction Permit -
Permission is hereby granted to Construct( )Repair)(XX)Upgrade( )Abandon( )
System located at 1 360 Lary Dunn Road Cummaggid r MAss-
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to
�E comply with Title 5 and the following local provisions or special conditions.
Provided:Constructio must be completed within three years of the date of this(e . it.
€e Date: ��� ���D Approved by
Ali
` �< :.
a 4 1/&99
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS)
I Jose h P, p .Macomber Jr..hereby certify that the application for disposal works
construction permit signed by me dated 11 /2 2/0 0 concerning the
property located at 1 360 Mary Dunn Road Cummaquid,Massmeets all of the
following criteria:
• The failed system is connected to a residential dwelling only. There are no commercial or business
uses associated with the dwelling.
• The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch.
• There are no wetlands within 100 feet of the proposed septic system
• There are no private wells within 150 feet of the proposed septic system
• There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
• The bottom of the proposed leaching facility will not be located less than five feet above the
maximum adjusted groundwater table elevation. (Adjust the groundwater table using the Frimptor
method when applicable)
• Lf the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed
leaching facility will =be located less than fourteen(14) feet above the maximum adjusted
groundwater table elevation.
Please complete the following:
A) Top of Ground Surface Elevation(using GIS information) <'
B) G.W. Elevation + the MAX. High G.W. Adjustment . 7 = o&Z 7A
DIFFERENCE BETWEEN A and B
SIGNED : f DATE: 1 1 /22/00
(Sket opposed plan of system on back).
Q:hnith folder,cert
w
/7 I�
V \
Q O
5 ' Dig out all,=aroudd
and under the 500
gallon chambers.
35 'X23 'X2 '
1
�a
5 ' dig out all
around the 500
gallon leaching
chambers.
35 'X23 'X2 '
No. ...... FEs.. _....._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF t H EALTH
' 73
• A'pliratinn for 11isposal 'lurk C��a� r c#uan erntit
- Application is hereby made for a Permit'to Construct ( ) or Repair ( an Individual Sewage Disposal
System at: .
.............1_?z. .. ...: '.1:.cA, ..1 .w. !:.. ....:..: .:... . 7 w...� art__t' ..........................
Location-Addressor Lot No.
.._.:_...._.,!�'1_r.. .. �. � ,. �...�...--------.•...... .. ------ ................................................_._..... .
►Wa . --..1r.1.F�..h _.� 1 1 ........... ............/�� '�i/l t/N�j Address
...----•-•.......-- .
' ..
q Installer Address ••
UUp Type of Building
� . . Size Lot.............................Sq. feet
Dwelling—No. of Bedrooms.....`a3.- _:----•-------------------------•.Expansion Attic ( )' Garbage Grinder ( )
aOther=Type of Building .................:.......... No. of persons.......................... 'ShowersCafeteria ( )
•Other fixtures ---------------•---••---......--------- .......... ------------------•----.....---...................................
WW Design Flow.......... ..-?...........................gallons per person-per day. Total daily flow.�-_;?_1.....................gallons.Se tic Tank—,Liquid ca acitY............gallons. Length................ Width................. Diameter._:_.. ...... Depth................
x 3 Disposal Trencha No:..........:
.::..... Width........ ........ Total Length__._........_:_..- Total leaching area...............::..sq. ft.
� � �Seepage Pit No......... .......... Diameter._... .. .. .De Depth,below inlet...... -
Total leaching area...................sq. ft. .,
.Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed bY.......................................................................... Date........................................
Test Pit�,No. l................minutes per inch Depth of Test Pit..................... Depth to ground water........................
(z, Test Pit No. 2------------ --minutes per inch Depth of Test'Pit.................... Depth to'ground water....................
R+ " •---------=--•--•--=-----•----------------------------------------------------------•-•---•--.••... =•-•------...-•••-•-••--•......-•---•......-----------
O. Description of Soil..........................................................................................................................................................................
V ..................................•--.............-----• ------.........----•--•-•--•-------------.................------. ,
W
-- -•-------------------------------------------- -:.----•-----••. :._..-----•......•....----•------•-•--- ----------- . ------•-- .
U Nature of Repairs or Alterations—Answer when applicable.:, 5�s '.�......a....4 .�_�('0..... -cam
Agreement:
The undersigned agrees`to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITi 1E 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_ ..._' ,.. ---- - .�-.
. ` Da Q
Application Approved-By... - r� v
s ate
Application Disapproved for the f ollowin-g reasons:.--- -- ---------------------------------------------------------------------------------------------------------
- ---- ------ ---
�f✓�r -
..._. - Date
..... Issued_=-------------- ----------.............------•----
Permit No.. ..� R Date
,.•...-.o .>:. �:y, ar'a. •:w,;:::tq-b��y,:,x..:.rr`.r.'�._ .v� �r _. -.... tir....: ,.._� _ ... ., �- _ � ..._ _.- . ...ti-
i. .V..'
�46
No...
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Appliration for Disposal Works Tonstrurtion Frratit
Application is hereby made for a Permit to Construct ( ) or Repair ( 4)'`an Individual Sewage Disposal
System at:
..--•-----...9 ...»......:.. w�N ...... ............... w_ )yvt,..?... t�i , >.......................................
Location-Address Ar Lot No.
-- ».»^» :.- �; rn ��......................... ................... .........................................................
U'wner
Address
Installer t Address
Type of Building Size Lot............................Sq. feet
aDwelling—No. of Bedrooms....?..................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
d Othefixtures .
Design Flow......=...............................gallons per person per day. Total daily flow-- �__ ......................gallons.
Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Depth below inlet._...61..�_...... Total leaching area..................sq. ft.
3 Seepage Pit No-_•_-•___ ___________ Diameter..... �__.___. p
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
.-a - 1
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........................
x --------------•-----•-----------.............--•-------.....---......_._............---------------........----•---------------._....---•-...................
0 Description of Soil........................................................................................................................................................................
V ............... ...--......--•----•-------------•---•--------------._......---------......-----•-•---•--......---------......_..----------•-•----•---•--•----...............-----•-•--------____.....__.
W
U Nature of Repairs or Alterations—Answer when applicable..._ -------a�'........ ...4s '
Agreement: 1
The undersigned agrees'to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions.of TITLE 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........ �t1' /'�._�._
r •--•-------
C/ Date
APPlicationtApproved BY ....... ......; ..__.. N!!! _._.... �b�/
ri� Bate u
Application Disapproved for the following reasons:....�.....................:...........................•.-_•-_.-•.•-----...•.•.-••---_-_._-___-_...-_..._.
--------------------------------------------•--•-......----...........•.
I�Yr� Date
PermitNo.- ........-•----_.... Issued•.-•----------•-----------------------••••-••........---
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Tertifirab of Tontphaurr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
by..... .... '.. La. •L
r '1'nstaller
at..............A- 1,. _��y :n!1�!4S`J = �: ... - �------- c
has been installed in accordance with the provisions of TITL,: j of The S`ate Sanitary Code as described in the
application for Disposal Works Construction Permit No...._ -�(Q�� _.. dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SAT ISSF/A�CTORY.
DATE ...- __.'b b J )
............. inspector................. ........................................................
'-THE COMMONWEALTH OF MASSACHUSETTS _I
BOARD OF HEALTH
�a
No. ... FEE
Disposal Vorkii 0111notrnrtion firrutit
Permission is hereby granted......... ..............................................................
to Construct ( ) or Repair-( Jan. Individual Sewage Disposal System
at No............ s 7 .ZkL44 %
/// / /
as shown on the application for Disposal Works Construction Permit N -----____.�._� Dated.. ___/�_�i�_,�85Z__�!._
a
u ar or xe:adh
DATE............`-O`--��-------8.
--------•-----...----••----- C
. NAME OF OFFENDER %G,,,d o tl�'t f't M f��+ /_ D A R "�n 3 0 2
TOWN OF ADDRESS OF OFFENDER 1 FYI R. i it y!/'f t DN r V V
130
BARNSTABLE CITY,STATE,ZIP CODE t. DATE F B RTH 0 OFFEI�DEJ
pIF INE►p,. MV OPERATOR LICENSE NUMBER MV/MBREGISTRATION NUMBER
_
OFFENSE-,.-` �(y, I[ q ./��y ., r{ 'w /1
NAN\�'IAPI.F..A I "J A D� 1�.1 ,/�✓.)W Gde. 9 t 4,ir • / Y /
MASS. V !' U �' 0 �
i6j9
►ED NVy► O
ow e f r3 j�—J, 9( tip x. {e b ijh S-All 00 flpell . UJI
TIME AND DATE OF.VIOLATION'�` - - {} LOCATION OF VIOLATIO r Z'.
NOTICE OF 1d°��i teA:M P.M.)ION L7 a 200 y4� u { it,�
SIGNATURE OF ENFORC NG PERSON .,►+7y ENFORCING DEPT. BADGE N0. W
VIOLATION `� 1G ���1 I P � cl)
t o
OF TOWN HEREBY ACKNOWLEDGE RECEIPT OF CITATION X a
ORDINANCE Unable to obtain,sgnature of offender. G ►-
THE NONCRIMINAL FINE FOR THIS OFFENSE IS i /00,
Date mailed . W
W
OR YOU HAVE THE FOLLOWING ALTERNATIVES WITH REGARD TO DISPOSITION OF THIS MATTER.EITHER OPTION(1)OR OPTION(2)WILL OPERATE AS A FINAL
DISPOSITION WITH NO RESULTING CRIMINAL RECORD.appearing y y W
REGULATION befo eU The Barnstab elect to le Clerk,200 Ma Street,the above fine,either by
ya s MA 02601,or bymailing a check,money order P.M.,
rApostal note to Barnstable Clerk,P.OS Box 2430, W
Hyannis,MA 02601,WITHIN TWENTY-ONE(21)DAYS.OF THE
gDATE OFyTHIS NOTICE. a
B21RNSTABLE DIV SIONou desire to t COURT COMPOUN noncriminal
D MAIpr FIRST
ocee 9�ARNSYABLE,so MA 02630,Attrc 21D Noncriminal DISTRICT
Hearings d encloURT se a copy of this
citation for a hearing.
(3)If you fail to pay the above offense or to request a hearing within 21 days,or if you fail to appear for the hearing or to pay any fine determined at the
hearing to be due,criminal complaint may be issued against you.
❑ 1 HEREBY ELECT the first option above,confess to the offense charged,and enclose payment in the amount of$
Signature
/J
No..�... .. t�J�
THE COMMONWEALTH OF MASSACHUSETTS
... . BOARD OF E-1 E A LT__I .�
_.
.w.-_......OF.�iC O l-c�
Appliration--for Dwposal Works Tvnstrnrff t Vrrmi#
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at• L
•............... S..�P.....®..........��. � 'w'^' �............------ �3 . ..................................
Location'Address or Lob No.
............... _. K.-- -.....-- ..... . �a
G. �
wnP• •. �. .......... .................. -................__......._•.. ..............
Address
a •-•--'--....`. . ......
.S............................. ...............'tom.
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 ( )
Otherfixtures --------------------------------------------------------------------------•----------.
Design Flow.......... ....... gallons per person er day. Total dall. flow......._.. ___...------ �--••--•-'---gallons.
WSeptic Tank—Liquid capacit=.gallons Length....... Width._. ..__. Diameter. Depth................
x Disposal Trench—-yo..................... Width.................... Total Length........... Total'l' hing area....................sq. ft.
3 Seepage Pit No....... ............. Diameter....J..0__..... Depth below inlet...J6............ 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........................
G4 Test Pit No. 2................minutes per inch Depth of Test Pit.................__. Depth to ground water...._...................
x ---------------------------------------------......--------------------------- --------------------------------------------------------- ------
O Description of Soil.............................................................................................. ----------------•---------------------•=---.....-•------........_...•--•
W
V
W
x ----------------------------------------•-- -
U Nature of Repairs or Alterations—Answer when applicable........C.&t3.L?__.-7-.14.lti�..._...__.I_0�.....f—*B-
-------------------•-.•-.e-%40.......:�-----------..6... 3�.'-2� ��`�'C-Y.l a!u ....................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITLU, 5 of the State Sanitary Code—The and signed further a rees not to place the system in
operation until a Certificate of Compliance-has-been issued by e bo r a t L.
-----//------- --
Application Approved By....................... -• ....... .'4.!II.ILfJ..•. ----•--•----- ---------- ---- •-----ate .....-•--^..
Application Disapproved for the following reasons:............................
.....................'-----......---•----...........-•--•••----•'•--......------.._.._.......-----....._..-•-•----------•-------...---••---'-----•-•-•--------•-........................................
Date
Permit No. . ZEZ� .... ........... Issued......................................................
Date
f-6:
77
^�,�
No.... .�.�% � Fps...-��...
THE COMMONWEALTH OF MASSACHUSETTS
s
BOARD OF HEALTH._. - 33 4Q
..��.�CIw.. .:.......OF...v ? .w - ...------- ------
;
Appliration for Disposal ork'h Tonstrnrtinn rrrntit
Application is hereby made for a Permit to Construct ( ) or Repair (j_.)'n Individual Sewage Disposal
Yat:
S.
stem > .... . ... tl�i i <' '�✓ f 1�1;�,�u�,_ 4.._
--•^.`� Location-Address `••----...................................................
or Lot No.
......................°.«-_N.„ ,..4;;,1�. ;� ram . � `'.. --
.................. ...........
W -- Owner
Address
..... - ^^ ...................
rt
1p
a '-''---. ..----`-�-........ .._::F.._f._.............................••-•- -F c...9 "!�.!' ........._.....
Installer - .Address •...... .........................
Type of Building Size Lot----------------
V --•�"-� .-----._._..Sq. feet
Dwelling—No. of Bedrooms.... .............................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building -------_-__--_---------- No. of persons............................ Showers ( ) — Cafeteria ( )
d Other fixtures
Design Flow....... _ ar: .•..._.._.._.gallons per person per day. Total daily flow.._._... ...... .%'" ............gallons.
...
W Septic Tank—Liquid capacityv.'. :Igallons Length.__....._ Width.._..``-{_..... Diameter................ Depth................
x Disposal Trench—N,o.....................Width.................... Total Length..................... Total leaching area-___----_--------.sq. ft.
Seepage Pit No.......1.............. Diameter....—0r...... Depth below inlet.._l -1......... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
a Percolation Test Results Performed by.......................................................................... Date........................................
1.4 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 ---
•------------------------------------------...............................................................................................................
Descriptionof Soil -------------------------------------------------------•----•---•--------------------------------•-------•------------------..........••......_......_...-•-•
x
x ............................................................••••--•----•••-----•-•-------•---•-•-•--------•-•••...--••-------------- ----.................................................... .• .
---
U Nature of Repairs or Alterations—Answer when applicable....... _ < _ � _! a"_ ---_•-<...�t�-.••-JDV7-"
Agreement: 1
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 bith'e bolr health.
f ��`
-ned- _ - ................... ?� t
g •` -
APPlication Approved BY s �- - l=• .............. _ k o.
Date
Application Disapproved for the following reasons:........................................................ .................................................
.................•--..........------------...------...-------•-------•----•-•----.........-•----.......................................................................................................
/ Date
Permit No._.,`T_ -{---n -------•--•---- Issued. --•--------•-•---•-•.................._
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
:..... .. �. ...- �..,. �` ,. �•P. ...............................
(9rdifiratr of Tontplinnrr
THIS IS TO CERTIF��That.the Individual Sewage Disposal System constructed ( ) or Repaired
bY_••-•-•.........................•_-_!,_..... ...._.... ---"y _1--,A_<� ------. ..........---.....-----•-_........------...........-----............_ (..
Installer
has been installed in accordance with the provisions of TI"L: 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE C NSTRUED AS A GUARANTEE THAT THE
SYSTE ILL UNCTION SATISFACTORY.
DATE-- -.--. _........-•••__......•..................: '......... Inspector.�. -
THE COMMONWEALTH OF MASSACHUSETTS
BOARD�OF HEALTHY
(.......kk.V-....OF....
No`><C.r?.......... Fig aA& ......
Disposal Work no#r ion rrntit
Permission Is hereby granted........_��;.�----------� _
to Construct ( ) or Repair ( an-dlldividual Sewage Disposal System
at No. ". . 1 - �• t
Street � ` --
as shown on the application for Disposal Works Construction Permit No?{�-.p._.._.--v� --�Dated..___ - -tr�!.�s'_ •............
•---••..•..'- — l�V"�� Cr -..........................................
/ -_____
Buanl of llcalth
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Lb SEWAGE # 1W" 79
yII.LAGE �JA@tilb MON-s ASSESSOR'S MAP & LOT 3
INSTALLER'S NAME&PHONE NO. oak-O h 151-K, 1314'
SEPTIC TANK CAPACITY 960e3 r-A l r
LEACHING FACILITY: (type) 4%9 W k (size)
NO. OF BEDROOMS
BUILDER OR OWNER
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PERMTTDATE: COMPLIANCE DATE:
Separation Distance Between tlie::
Maximum Adjusted Groundwater Table to the 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
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SEPTIC TANK CAPACITY / CA( t
LEACHING FACILITY: (type) �Z (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
'Separation Distance Between the:
Maximum Adjusted Groundwater Table to the 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
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DATE PERMIT IS.SUED ����,� �
DAT E COMPLIANCE ISSUED C� �
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NO. OF BEDROOMS 3 PRIVATE WELL ( �3BL CI W� ._L�"
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DATE PERMIT ISSUED: tY
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes° No
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