HomeMy WebLinkAbout0101 MAUSHOP AVE - Health 101 MAUSHOP AVENUE,BARNSTABLE
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TROY WILLIAMS
SEPTIC INSPECTIONSIto
Certified by MA Department of Environmental Protection a ` F (508) 760-1819
40 Old Bass River Road
South Dennis,MA 02660 o r f 1 ' 9 O
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Department of
Environmental Protection
William F.Weld Trudy Coxe
Governor _gKr�y
A W Paul Celluocl David B.Struhs
LL Govemor Com AsIoner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
/ CERTIFICATION
Property Address /o m6k rS Aue �arN S L�< Address of Owner. M(�v,y
Date of Inspection: 6 1/y /9C (If different)
Name of Inspector.--7—k-oyy W I ; v.vk S
Company Name,Address ad Telephone Number.
S�e 14bo J c
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The System:
Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails
Impector's Signature:----- Date:
S
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the
report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B, C,or D:
AJ SYSTEM 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.
BJ SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes
inspection.
Indicate yes, no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If"not determined",explain why not)
The septic tank is metal,cracked,structurally unsound,shows substantial infiltration or enfiltration,or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a poaforming septic tank as approved
by the Board of Health.
(revised 11/03/95) 1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: /0 A4,.
Owner. LC t_
Date of Inspection:
B)SYSTEM CONDITIONALLY PASSES (continued)
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):
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(a) are replaced
obstruction is removed
C1 FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: lv/4
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 FUNCTIONING 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 within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water
supply well, unless a well water analysis for ooliform 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.
3) OTHER
(revised 11/03/95) 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 0 / A4 4 J S o
Owner. /
Date of Inspection: C
D) SYSTEM FAILS: Ivl4
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 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 1/2 day flow.
— Required Pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of tunes pumped
— 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 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.
E) LARGE SYSTEM FAIIS:W/4
The following criteria apply to large systems in addition to the criteria above:
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:
— 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.
(revised 11/03/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: /V 1 I C u 5 1—oe
Owner. L e-
L
Date of Inspection: /// / 9
Check if the' following have been done:
V Pumping information was requested of the owner, occupant, and 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.
�Ae built plans have been obtained and examined. Note if they are not available with N/A.
_VThe facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow
✓The site was inspected for signs of breakout.
All system components, excluding 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.
i� 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.
The facility owner(and occupants, if different from owner) were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 11/03/95) 4
. y
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR
M
PART C
SYSTEM INFORMATION
Property Address: P
Owner. t
Date of Inspection:
/ 7 C
RESIDENTIAL FLOW CONDITIONS
Design flow:g � won
Number of bedrooms:_
Number of current residents:
Garbage grinder(yes or no):7
Laundry connected to system(yes or no):-2:�—f S
Seasonal use(yes or no): /Y6
Water meter readings, if available:_ -
Last date of occupancy:
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow:------gallons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non-sanitary waste discharged to the Title 5 system: (yes or no)
Water meter readings, if available:
Last date of occupancy:
OTHER (Describe)
Last date of occupancy:
GENERAL INFORMATION
PU�M/PING RECORDS and source of information:
/"V�✓A"/' r`� mil.`1 � C/� !-S s�JG/ /In-�d d
System Pumped as part of ups 6 �"` h c .( rM lil o s+� p t,-��•
pection. es or no) /V c
if yes, volume Pumped: ¢alllons
Reason for pumping:
TYPE q.F SYSTEM II
Septic tanbdistribution boxisoil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) (if yes, attach previous inspection records, if any)
Other(explain)
APPROXIMATE AGE of all components, date installed (if!mown) and
.�source
Loof informatio�6 P', �j 111 I� �l� �o.:"- Lv', I f- tr� --0� aJ •S / �:�,�
S g y>cr �.5_ L u,
Sewage odors detecte� when arriving at the site: (yes or no) /116
(revised 11/03/95) b
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 1 v (
Owner. L t
Date of Inspection:
SEPTIC TANK:_
(locate on site plan)
Depth below grade:
Material of construction: Vconcrete_metal FRP_other(ezplain)
Dimensions:_
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle: 0 ,o�
Scum thickness: o NC
Distance from top of scum to top of outlet tee or baffle:/V0 S IC—(J4-1
Distance from bottom of scum to bottom of outlet tee or baffle: I/O 5< "Li
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.) <f_o •c oo—Cj >r .
C.� t or L . 4 04-
Lc cA_ 6
GREASE TRAP. & ,A
(locate on site plan)
Depth below grade:
Material of construction: _concrete_metal_FRP_other(ezplain)
Dimensions:
Scum thickness:
Distance from top of scum to top 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 level in relation to outlet invert, structural integrity,
evidence of leakage, etc.)
(revised 11/03/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
// SYSTEM INFORMATION(continued)
Property Address: d
Owner. ( �C
Date of Inspection:
TIGHT OR HOLDING TANK Y//)
(locate on site plan)
Depth below grade:
Material of construction:_concrete_metal_FRP—other(explain)
Dimensions:
Capacity:- rallons
Design flow: gallons/day
Alarm level:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BO)L
(locate on site plan)
Depth of liquid level above outlet invert: -�-J-ci(
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box,etc.) — �� )r W aS -
A hJ CJ L t c'-c.� U✓' k � c or�ta�
PUMP CHAMBER: A/!4
(locate on site plan)
Pumps in working order:(yes or no)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 11/03/95) 7
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Addresx
Owner.
Date of Inspection:
G/ly/ 9�
SOIL ABSORPTION SYSTEM (SAS): >/
(locate on site Place, if posable;excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type:
leaching Pit', number:oc— G �xG 4-co,�� p , �—S : n m o yt c� ",A .3 "o H c✓c
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number,dimensions:
overflow cesspool, number:
Comments: (note condition of soil, signs of hydraulic failure, level of n po ding, condition of vegetation,etc.) d ,��
µ� w~ \ 7
I /
L
1�0 lot
CESSPOOLS: A—/1/9
(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:
inflow(cesspool must be pumped as Part of inspection)
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:
(locate on site plan)
Materials of construction:
Depth of solids: Dimensions:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 11/03/95) 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner.
Date of Inspection: G
SKETCH OF SEWAGE DISPOSAL SYSTEM:-
Include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
3�
/OUVy4��J �
5Wr;
1
DEPTH TO GROUNDWATER
Depth to groundwater: feet — adjusted high groundwater level
method of determination or approximation: S J � o ;
.e ws,
9
TOWN OF BARNSTABLE
o�
LOCATION E WAGE #
VILLAGE ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO. A & B CANCO 775-6264
SEPTIC TANK CAPACITY / d
LEACHING FACILITY:(type), �l� /s4®� (size), '��Sot
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER lee
P DATE PERMIT ISSUED: -�-
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
G � -
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�Y ++
1
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TOWN OF BARNSTABLE 1
LOCATION I d 1 A10-`�' !r► SEWAGE#
VILLAGE ASSESSOR'S MAP &LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY als
LEACHING FACILrI'Y: (type) r
NO.OF BEDROOMS �_ v
BUILDER OR OWNER L_e—e _ o
PERMITDATE: COMPLIANCE DATE: ,S
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 '7-,W
It1 )
� 3
' � `l7 �
t � �
ASSESSORS MAP NO:
Fj?:4.?a.... PARCEL NO:
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® Off-` HEALTH
........... C��tt�'1 OF.... Ccrh� 4?Q��.............................-.........................
, pphratiun for R_qvuual Works Tome rnrtiun Frrutit
Application is hereby made for a Permit to Construct ( ) or Repair (*4 an Individual Sewage Disposal
System at: I
...tol.... f�N.S.!�� .._�:s :. 4rns 4 .................. ..............................................................•---•-••-•--•-------•--•-•-.....----
n Loc ton-Address or ram,No.
E;�r...411.'�!�C:.....oxj- --------------------------------------•------- dal.•/1�I A�jus._a�,...��?�....._15f,4��r!i4.....................................
` Omer_ 56li�/X+ Add s� f ......_.....
Installer Address
Type of Building Size Lot........................:...Sq. feet
U Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No. of persons............................ Showers — Cafeteria
a Other 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........................................
aTest Pit No. 1................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........................
fYi ------------------------------------------
--.......
--------------------------------------
-------
•...
..........
•...
•------------------
•-•--•.............
•--•-
0 Description of Soil.................................................................................... .................................-.................................................
x
W -- --••--------:..-------• ----------------------------------•-•--•----•----•--------------•----------•---- -- -- -----
UNature of Repairs or Alterations—Answer when applicable_714.0 __46-DD:.7.aA... .�?1�F__.w�6 .......
czs T
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Agree :
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of i ITHZj 5 of the State Sanitary Code— The undersigned further gree not to place the system in
operation until a Certificate of Compliance ed by the boar
Signed----- ..............................--- --------------------•----------------
Date
Application Approved By.............. .... .�-- "' -------------------------------•--- -----------,7� 3 -�S$'......
Date
Application Disapproved for the following reasons:-------•------------•-------------------------------------------------------------------------•---•--••.........
--------------------------------------------------------------------------------------------------------------------•---••-•----••----------- ----- ---- ------------- --------------------..-----•---
Q► Date
PermitNo............ -�..... ..................... Issued.......................................................
Date
TTS
1
..tea ,...
No...U. :� -- �� FEs.............-..........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...........................................O F..........:......... ...-.�!-..-...
Appliration for Disposal Works Tonstrurtion truth
Application is hereby made for a Permit to Construct ( ) or Repair (- -) an Individual Sewage Disposal
System at:
+ r
1 Location-Address or Lot No. }-
r +
Owner r Address
Installer Address
dType of Building Size Lot............................Sq. feet
aDwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
P., Other—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
a Other 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 ( )
a' 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........................
---------------•--------......------.._.....-----...----.....--••-•------------------........................................................................
0 Description of Soil.............................................................,..........................................................................................................
W ------------------------------------•--•----------------------------------------------------------------------.------------------...--------------------•---------•------------------------....--•-•----
Nature of Repairs or Alterations—Answer when applicable...
1
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of T IT Li:p 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...................................................................................... ................................
C Date
Application Approved BY - r ................................... 53 -
Date
Application Disapproved for the following reasons--------------------------------------------------------------------'----------------------------------...._-_._..
...................••••--•---•••--•-•-------•••••--•••••-•---...••-••••--•••----••••---------•-----•-•-•--•••-•-•-•-----•-••------••-••---•-•-•-••-••---------••-•------•------•...•••••-•••--.._._..--
Q� Date
•--.-
Permit No...........-o_. + --------------------- Issued_.-•---------------------------•-•--- -•----
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
:...............................OF.................................:...................................................
Trrtif iratr of TontpHaurr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( , )
bY...................... .....1�..... vKrQ---------------------•--------------------.....-------------._...__.._._...... _ ......_ e .........._........_._..._._._.........-----
Installer
at........................................................................................................ --------------------------------------------------------------------------------------------
has been installed in accordance with the provisions of TITLE j of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No------- S-- 9- ------------ dated------------------------------------------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.---•------•--•••...... ............................ Inspector............... .................................................
THE COMMONWEALTH OF MASSACHUSETTS
r' BOARD OF HEALTH
r
1 !
No.._._.�' 1�
.... .. FEE.....................
Disposal Works Tonotrudivlaprrmit
Permission is hereby granted------- b.......-N1-•14iel -----•------------------•----•----------------------------••----------._........---........_..
to Construct ( ) or Repair (}�j an Individual Sewage Disposal System
atNo............[•0••l....... ------ --------1'F-txC.................------------treet-- ------ e-------------•--------------------------------------•-•--___-_____
S _,f
as shown on the application for Disposal Works Construction Permit No.- D:_1 GG _ Dated..........................................
r - Board of Health
DATE .............................................................
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
--LO_CAT_LO N
IVA09'140 OR,
D r�,T_E_P_E-R_Iv.1-C-1_S SU-EC) 'l&" � - _ -
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Nor..--••--•-------•----...
Finc............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD Of HEALTH
L'd t/y1------------OF........... .. .... . .. ..
Appliratinn -for Bbipoiittl i9orkii Tonstrnrtinn Prrnnit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
Location•Address 4 1 or Lot No.
......._�.. ..`. .................... - -•---••-•..............................................
Owner,
�Q Address
a - i �"........... I t --••---••••-•-----•-- •-•-•-------•••-------•--••-.-••-•--•-•-•-•-•-•--•----••-•------••-----------•-••---•--•-••••---
•,a7 Installer Address
Type of Building Size L ......))_17_Lf V-----Sq. feet
Dwelling-No. of Bedrooms __________________________________________Expansion Attic ( ) Gafbage Grinder ( i
per, Other—Type of Building --No. of persons____________________________ Showers �r Cafeteria ( j
Q' Other fixtures ------------------------------- - -
W Design Flow... -----------________r__________gallons per person per day. Total d ' flow....... ____________--.-.._--gallon
WSeptic Tank�iquid capacity.F- gallons Length_._.._,...... Width--- .......... Diameter________________ Depth................
x Disposal Trench—No_____________________ Width-------------------- Total Length-------------------- Total leaching area--------------------sq. ft:.
Seepage Pit No..................... Diameter____________________ Depth below i et_____ ____._ _.__ Total leaching area-___--____-_______sq. ft.
Z Other Distribution box ( ) Dosing tank ( ) 4 ' /o—;Z - 7
Percolation Test Results Performed by------ ----------- ....................................................... Date......................... -------------
Test Pit No. 1....._..........minutes per inch Depth of Test Pit.................... Depth to ground water---____--____--__-____--
Lti Test Pit No. 2................minutes,per inch Depth of Test Pit.................... Depth to ground water-..__-_-_______-_-____--
0 ___A .............
c
Descri ion of S 'L___ Q_-___d' G� [.o__._.�_ °�// 6/6•�— _ __- __:----
V Nature of Repairs or Alterations—Answer when applicabl�_____________________________________________________________________________________..........
------------ ---------- ---- -----------------------------•-•----•--•-•-_.___._._.__-----•------------•-------•--------- -•------------------------ ------------------- ----------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI 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_... r ._..- ------•---- ---- -----_-•---------
,J Dates/
Application Approved BY . ('� - ®s�-------`-rt
Date
Application Disapproved for the following reasons-------------------•_---____-____-_---_-_-------------_-_---------____--__-_------------------__----_______------
------------------------------------------------ -----------------------------------•--------------------------•-----------------------------------•------------------- ------•-----•---------•-----•-•-
Date
PermitNo--------------------------------------------------------- Issued....... .............
Dat
- i
No. Fe$............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O HEALTH
rt,./�-, - oF........... .. ..... .:.. .. - ---:-- .... .........
Application -fur R!ipuutt1 Works Tunstrurtiun Vrrniit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
-------- v-c l IP -e
- `� -----------------------------------------
Location_Add less or Lot No.
G�-l�i��_1y----••._...�:---------5 - ` --------------------
Owner
`p Address
•--- --•--• •-•••--•---•--•---•-
Installer Address t�
UType of Building Size Lot .}}?y!-.._._Sq. feet
Dwelling_,I_ _o. of Bedrooms ________________________________ _____Expansion Attic ( ) Gai`bage Grinder ( )
g __��_11LN.(_No. of persons____________________________ Showers (%-�� Cafeteria ( )
a
Other—Type of Building
a' Other fixtures ----------------------------------
W Design Flow--- ......._...__________________gallons per person per day. Total dail flow........�G�....................gallons.
G: Septic Tank�iquid capacity] gallons Length------6------- Width-__�.-_.. Di, ----- Depth-__-____-__---
Disposal Trench—No- ____________________ Width-------------------- Total Length___________._______ Total leaching area--------------------sq. ft.
3 Seepage Pit No--------------------- Diameter_____________._..... Depth below __met..._ ____-- _._ Total leaching area____-_--_-_______sq. ft.
z Other Distribution box ( ) Dosing tank ( ) (JO ' 4 h /U-,2 - 7.-
a Percolation Test Results Performed by.......................................................................... Date...................-----------------
....
Test Pit No. I................minutes per inch Depth of 'Pest Pit-------------------- Depth to ground water-.-___-_-________-_---_-
�14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water__-_--______________._..
Descri Description of S 1 ...G2 ................... `( '--
U Nature of Repairs or Alterations—Answer when applicabl ----------------------------- -----------------------------------------------------------------
------------------------------------- -----------------------------------------------------------------------------------------------------------------------------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI 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. /,1
Signe i �� 1 U — ��� ���
Date
Application Approved By.. "%— G ee ---- --- l�✓lil ------ ---7-'�—
Date
Application Disapproved for the following reasons__________________________________________________________________________________________________________________
-------------------------------------------------------------•-•---------•---•-•----...--
G
Date
PermitNo......................................................... Issued------- ---------------•---
Dat
THE COMMONWEALTH OF MASSACHUSETTS
BOARD HEALTH
�yf L"y ' l ��... .... .........O F......... .. . ./. . ...
U.rrtifirnte of 101,11mplinnrr �-.
TH `7�O,CER"lIF , That the Individual Sewage Disposal System constructed ( ) or Repaired
by --,{ ------- -- --- -------- ----------------------—� Installer .,�.._../ �
has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit NO.Z�--- __^� ............ dated_-__/G_-:.�. __ :-�_`.......
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT TIME
SYSTEM WILL FUNCTION SATISFACTORY.
DATE. �r--� 4 -----------•------•-•-•----.... Inspector---- -- ;,
................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD Of
HEALTH
� ..................�./ a
a�No......................... . FEE------...-------........
Dirivun r ur4,i
�un - rtiun Prrmit
gated � r)Permission reby ~ J. _ "•d:s.•-••--•--_.._..-•------
- -__----•-•--•-
•------•--•-••----) an I dividual Se e Disposa' ystemto Construct or Re------------
asfiat No.. -shown on the application for Disposal Works Construction Permit No--------------------- Dated..........................................
--------------------------------------------------------------------------------------------------------
7 J Board of Health
DATE ` Q•------- - ------------- ----- ------------- ----
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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