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HomeMy WebLinkAbout0023 WINGFOOT DRIVE - Health 23 Wingfoot Drive Barnstable A= 349 - 075 FROM :CARMEL—CRIER FAX t}0. :5067606644 Jul. 20 2007 09:49AM P2 _ COMMON'WEALT14 OF MASSAC HLiSET"i'S /Zti��rWXA.1 E-ECUTNE OFFICE OF EINAgRONMENTAL+ AII't,S DEPARTMENT OF ENVIRONMENTAL PROTP-C'I'ION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSES$Nd NTS 24 SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PkRT A C1E RTInCATIOty , Property Address: i ► /� it 1 rn _ Qw►rWe Name: Owner's Address; P- Date or Inspection; t Nlamc of Yraape6tgr;( so Print f Company Name, Mailing Add►vss, 10 Telmpriotte Nnnaber: �rK� CERTIFICATION STATEMENT 1 certify that I heve areOt;elly ifls : 8 petted tsae sewage disposal gyaaern at this address a rd that the infortna[ion repclrle ' below is true,acct�9lO end cottipiett tl4 q!'tha tir±te ofthe 1"18pection.The Inspection was peri~aritted based on rRXAff training;and exPlrleace in the proper fmction ad maintenance of on site sewage disposal systems:I attt n D�Y� approved systetn inspamor pmrsu aut to sotion 13.340 of Title 5(Jit)CMR 15 o0p), The;Ysteir,: :.; Passes Conditionally Passes Needs further Evaluation by the Local Approving Authority Pods Inspector's S*listure: Date: .' The system irfspector shall submit a copy of this inspection report to the Approving Authority(sv%rd of Heal h or DPP)within 3tl clays ofcompiating dhi9 inspection. if the system is a shared systc;m or has a design now of,1000 gad or greater,the it peelor and the systaOt owner shall submit the report to the appropriate regional officer;DEFT.The original ebould be sent to the ttyatatn owncr acid espies sent to the buyer,if applicable,and the appro:r rZ�authority. Now and Comments ****Tbls report only describes conditions me the time of inspection and under the conditions of use at that time.This inspection does not address low tho system will perform in the futyry antler the same or different conditia"X of use. Title S Ins .. 'c+t<p Gil, Fo rm tm 611 �0 Si10 page l r Xyj 9T:zj ro/zo 900Z FRON :CARMEL-DRIER FAX NO. :5087606644 Jul. 20•2007 09:50AN P3 Page 2 of 1] OFFICIAL INSPECTION FORM—NOT FOR VOLUNT,,RY ASSESSMENTS SUBSVRFACE SEWAGR J)j$ SAL SYSTLr1VI rNSPECTION FoRm PART A CERTII+'ICATY'ON(Continued) i'rOperty odor®n; L Owner: ` yid ---- DAN at inspection., Inspection Siomwiry: Cheep A ACA)or iE/ALWM complete a18 of 00CUOo D A. 9yeteM passes: 1 have^not fowd any itiftirtmation which indiestes that any of the failure criteria described in 310 CUR 1 �or in 310 CMR 13.304 exist.Any failure crittriA not evaluated are indicated below. Conmments: 6> System C'oaaditioupy Pam; One or more eystAm Componeints as described in the"Condiliortal rases"secti*n need to be repiaaed of rapaited.The system;Upon completion of the repleoamont or repair,as approved by the Bo •of 1•lrsltli,wi11 pass, Answer yes,no or not.dctcrmirred(Y,N,ND).in that for Vx following atal ents.'if"not deterinhied"please. explain. The septic tw A is metal and over 20 ya ars old*or the s (whethar metal or not)is sirueturally unsoauad,exhibits substantial infiltration or otfiltrauion or hurt is imrntaaent.System will pass inspection lithe existing tank is replaced with acomplying septic taut[as' roved by the Board of Hcalth, OA metal septic tame will pass inspection if it Is st y smeared,not leaping and ifs Certificate of Complia;nt$ indicating that the tank is less than 20 yews old is aliable. ND explain: _ Obumadon of sewage beck, or breg out or Wgh stater►water level in the distribution box due to broken or obstructed plpe(s)or due to a b settled or uneven distribution box.System will pats inspection if(with 4M?oVa1 ofi�oerd ofl"lealth): ,�.,., bsolcna pEfae(a�earaasepiacod obsttaWon>h removed dinrlbutim box 13 levsjW or reply&ed IUD explain: The m required pumping mor4 urn 4 tim as a year due to bracken or obstructed pipe(s),no system will pas itispe ion if(with spproval of the Board of Health): broke&pipe(s)are replaced obstruction is rmoved ND explain; y0p�I YVA I.T:IT znizn MW FRCN :CAR�IEL—GR I ER FAX NO. :5037606644 Jul. 20 2007 09:50AM P4 {1 Pale 3 of 1 I OFFICIAL WFEMON FORM NUT FOR V0L'CJN7'A.1ltY ASSESSMENT ';�gl1IiFAC SEWAGE d)IS 4SdaL SYSTEM"INSPF; SL �I+C!'N FORMS PART A CERTIFICATION(onntinued) Property Address- Owner; ' Date of llnspeetiou; ��y C. Further Ev2143tloh is Required by the Board Of Heaith; is.failing to prof public health safety the environmerrty the Board of mcaith in order to d ermine if thu svatern t• Sybtom ta111 past+unless Board of Health determines In allordance with System is not functioning itt.a manner which will protect public haatf CMR refety aM the en3(i)(b)that a the _ C6trep=1 or privy is within 30 t0tat of a surface water Cesspool or privy Is witbin 50 feet of a bordering vegetated tland or a,nit marsh a- System will f>slt dttlalE the Board of Heaith(p9 ttblit Watrr Supplier,if$ny,)dotermines that the system is functioning to a manner that prouai;4 t public health,safety and lttvironnuemt: _ The system has Aseptic to k and soil orption system f SAS)and site SAS is within i UO feet ore t wfRee'water supply or tributary to a surf water supply. The system has a septic tank an AS and the SAS is within a Zone I of a public water suppf y. _ The sysicrn has a septiq t Ctl.SAS and the SAS is within 50 feet of a private water supply well, The system has a septic 'Old SAS and the SAS is less than 100 feet but 90 feet or more Ftam a ptivate water supply we114 .Method used to determine distance *This 9ystern passes, the well water analysis,perforated at a DEP certified laboratory,for eoliform bacteria and volatil rganic compounds indicates that the~yeti is free fr th om Pollution From that facility and the presence ofp ania nitrogen and nitrate nitrogen is equal to or iM.than 5 pprn,provided that no other failure rriteria a triYgered.A copy of the a<nalyais muat be attached to this form. 3. Other; --�—�— — a �09f�j ?LY,a LT�zT TO/r;0 A00� FROM :CARMEL—GRIER FAX NO. :5087606644 Jul 20 2007 09:50AM P5 y Page d of I 1 OFFICL4L 114E PEC'l ION YORM"—NOT FO R VOLUNTARY ASSYMME ►TS $U13SURFACE SEWAGE DWOSA d.MTEM INSPECTION FOB PART CERTI CATI+0N(continued) Property Address.� Owner: Dade of imsptdi6n;. D. system P141ure critorla applicable to all systems: You Vq2t indiiparo"yes"or"na"to Cab of thg lbilouing for at8 inspections: Yes No --- Eackupofwa$a into facility or system component due to overloaded or clogged SAS csa cesspool ,rl✓ Disobarge oa PM&S Of OfPlaont to tha 811r6t:e of the ground or 9urfgR®waters due to an overloaded or clogod SAS or cesspool i 9tatia liquid level in W diathbution box above outlet invert due to an overloaded ur clogged SAS or cesspool Liquid depth in cesspool is Icas than G"below invert or available volume is lees than°/a day flow Required PumPing"Wo thin A dmea'A the last year A=dUO to CIOWd Or obstru ctmd plpe(a).Nt=bfff of time pumped oe Any portion of the SAS,cesspool or privY is belo'iv high ground water elevation. Any portion of cesspool or privy is wltbttt.100 fW.of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 ofa public well. Any portion of a cosepool err privy, within 50 fit of a private water supply well. Any portion of ra cesspool or privy is ten than 100 fset but gzeatea than 50 feet from a private water supply well with no 3coept"10 water"4 aq, Ymis,ITlaia a,Ystem Pam if the well water..analy$is, performed at a DE,$eertif➢ed laboratory,for collAwas bacteria acid volwtila argalale,Co isttlieatas that the weal i Tres from pallafion atom#iat iGtellity and the presence oPatmnionis nitrogen and nitrate nitrogen is equal to tar less than 5-ppm,provided that no other failure criteria are trlggerc&A COPY of the ssalysis must be attsehed to dais ftrm,j (YesaJlslo)The system fp &Ls,i have determined that one or most of the above Ail=criteria assist as ditcriucd in 310 CAD(15.303,ilaerefore the systems,fails.The system Owner sho,111d contact the Hoard of Health to detcrmine what will be necessary to correct the failure; E. Large Systems T To be considered as large system the system trtarst serve a with at deolga Dow of 10,000 gpd to 15,000 gpd a. You must iWicato eithtr"yes"or,w to Leh 0A lowlaag (The following criteria apply to large systems' ditia�t to the exheria above) yes no �. the system is within 400 ft f a swfgco Bringing water supply — the system 1s Within 2 feet ofa tribudary to a surfue driakiaig waiter supply the system is to in a nitrogen sensitive area(IlAterim wollhead Protection Area-TW?A)or a rapped w. Zone I1 of a pub a vater supply well If you have answered" or to any question in$oatlon B the system is considered a sigiaif9cant threat,or a mwwered "yes"In Section D ve the large system has failed,The owtlbr or gltu for 9(any large system considered a signif5cant thre .der Section F or failed under Secton D shall upgrsdo the systwA in meordance with 3I0 CIVIR 15,30-4.The system owner should contact the appropriate rogion€tl of a 4f the Do=iaartmaat, V0o(?ai Iva RT'iT Yo/zo 900Z FROM :CARMEL—GRIER FAX NO. :5087606644 Jul. 20 2007 09:51Aih P6 1 Page 9 of l i , OFFICIAL INSPECTION.FORM—NOT FOR VOLUNTARY A&USS1dtENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTII.M FORM FART B CHECKLIST Property Address• I Owner: Date orlaspogti o Check if the following have b4an done,You most ladizate or or"no"es tp ath of the folldwit� Yes No -4 _ Pumping infornmrlon was provided by thn uwnsr,occupm:t,or Board of Health Were any of the ayetem cornip011en4s pumped out in the previous two weeks? Has the system received normal flows In the previous two woek period 7 _.Loe Havc large volumes of water been introduced to the system reUntly or a part of this inspection 7 _ Were as built plaits of the system obtaincd and examined?(If they wore not available now as NIA) Was the facility or dwtlling lnbpccted xer signs of sewage back up? _ Was the site Inspected for signs of break out? Were all system cotWnenits,excluding the SAS, located on site? Were the septic tank manholes uncovered,opened,and the interior of the tank inspcctcd for the condition' of the baffles or tees,material of ooatstructiotf,dirtimi6na,depot of liquid,depth of sludge and depth of scum? Was the facility owner(and orcupsnts If difftewt fr6m owner)p-oAded with information or.tfc prnper maintenance of subsurface sewage disposni symtoms 7 The size and location of the Soil Absorption Syste;ao(SAS)on the site has b®®o determined hased on: 1'e ro Bxistati;;infosrnation-For racatfmple,it-plan at the Board of Health. A _ Detenuitsd in the field(if any of the failure critwria related to)Part Cis at issue approximation ofi distance is unacceptab)e}[3)0 Cib1R 15.302(3)(b)] snna YVA et:ti 10!71) tlnn7 FROM :CARMEL-DRIER. -FAX NO. :5087606644 .Jul. 20 2007'09:52AM P7 el Page 6 of 11 OFFICIAL XN,' IEC TION FORM—NOT FOR VOLUNTARY AssFsSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPtCTION FORM FART C SYSTEM 111YFORMATION Property Address; 3 ik 4 Ownct•o Date of latspoetlant FLOW G()"ITIONS RESIDENTIAL Number of bedrooms(dk9ign): Number of bedroorns(actual): . OESION now based on 310 CMR 15.203(for enmple: 110 gpd x N of bedtoonk): Z) Number of current rasld„nts; _ Does residence have a garbage grinder(yes or no): Is iassrtdry on a separate sewage system(yes or no):_q (if yes separate inspection required) . .laundry syatt m inspected(yes or no):P Seasonal use: ee ct na; (Y ) Water meter madings,if available(iaet 2 years usage(gpd))• sump pump(yaa or no);�6►ti last date of occupatrcy; ri "P' CUPrTfr ERCIA1APMUSTRI.AL Type of establishment; Design flow(based on 310 CNIR 19 Basis of design flow(seats/persq sgket`.); Crease tX= , present(yes or n .-Industriding present(yes or no): Non-sand' argtd io the Title 5 system(yes orAv);Water ra ,if®vsiiNable: Lut dittgyiuRa: _OTHER , CENE tAL INit!O RMA'ls I0N Source of information: Was system pumped as part of the inMection(yes or no): 7f yes;volume puknped:_�allem--Flaw was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM _L/Septic tank,,distriboCion box,soil absorption system Single cesspool —Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records.if any) innowlive/Alternative technology. Attad s copy of the current operation and maintenance contract(to be obtained&om system owner) _ Tight tank __Attach a copy of the Dr?approval —other(describe) Approximate age of all com oven date fella (if known)and source of wormation: o 0 vVe m seepage odors detected when arriving at the site(yes or nb): AA 6 9001l1 XVd OT:ZT TO/Zo 900,Z t FROM :CARMEL-GRIER FAX NO. :5087606644 Jul. 20 2007 09:52Ah1 P8 Page 7 of I 1 y hh 1 INSPECTION FORM-NOT FOR VOLUNTARY AS5ESSM>ENTg SUBSURirACE SEWAGE DISPOSAL SYSTEM INSPECTION�'SME Rm PART C SYSTEM INFORMATION(continued) ' Property Address: Owner: Date of Znspeetia BUILDING SEWER(locttte on site plan) . De t ptlr below g,*mtje; e° Materials of construction:„ ,cast iron __eqp PdC on c _other(explttirc): Distance from private water Cotntttonts Supply�s+eli or suction line: ( ottdrUan of join _etc). ,1 ts,veotu��,evidence of letskagc,etc.) SEPTIC TAN%; le (locate on Site plan) Deptl,below Srtede;TOL Material of construction: concrete metail e„•_fiberglxss polyethylene __cther(explain)_, if tattle+s metal list age: 19 430 conftt�rted by a Certificate of Cotttpiianre(yes or no):�(attach a copy of eereificate) Dimensions: � Sludge depth: Disfmcc from top of sludge to bottom of out st tee or bmtffle: Scum tlrkknaes. a, a Distance&OM top o scum to top of'Outlet tee or bade, S Distance ftrn bottom of scum to bottom of outict tee or ®c 1 Howwere d.rnenslerts determined: � u t Comments(On pttrnping recommendations,inlet and outict tea or b2W'c conditin strut 1' a>i r®laced outlet itra � tur'a integrity, Iiquid levels err�evidenne of lecleage,etc,}: ,'/ GREASE'11 TRAP:_(I(Mte on site plan) Depth below grade: Material of construction:—concrete metal fiberglass polyethylene (explain):. __. "` -- other .Dimensions: Scum thickness: Distance from top o�f strata to top of outle a or baffle.,_ Distance from bolt m of scum to bort of outlet tee or baffle: Date of last pumping; -^- Catntttertis(on pumping,reso ndations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet inver,ev' ante of leakage,etc.): 7 G00�1 X Vd $T:vT i4l40 900Z l FROM :CARMEL-GRIt—R FAX NO. :5087606644 Jul. 20 2007 09:52AN P9 Page BofII OFFICIAL INSPECTION FO% NOT.FOR VOLUNTARY ASSEM ENTS SUBSURFACE SEWAGE DISPOSAL SYSTEm, Il"sNSPECTION FopM PARS'C SYSTEM INFORMATION(continued) Property Address: 9.3 W i PISO Owner; bass elf 112mpee#i4Di�; TIGHT or Hd9'l,DtNG TANK: (Unic ntuat be p at time of inspection)(locate on site plan) Depth below grade; Material of cons vwdon: - Concrete tai „r.,fbeMlass__joiydt11y1erle. ether(explaim)! Dimensions: Capacity: liana Desip flow: Sefions/day Alum present{yes or no)s Alamt level! In working order(yea urn no)! Date of last p pin Commants{corxlit_ of alarm ae d float switches;etc,)- DISTRIBUTION BOX: (if presfl4 must be opened)(locate on site plan) Depth of liquid level above outlet lavtut: Comments(note if box i9 level and distribution to outlets mil,any evidenca of solids carryover,any evidence of Iockp� p into or v of box etc.)" 4� i 9 41 PUMP CHANISElt-� (locate nn si ollan.) Pt11Up9!ih SNOTlcing Omer{yes or _ Alarms in working order(yes no): Comtnent'4a(ants conditio pomp chamber,condition,afpLomps and appirtana=s,etc.): 8 BUGip1 xyd 6z:.Z1 10/zk 900Z FROM :CAR"IlEL—GR i ER FAX NO. :5087606644 Jul. 20 2007 09:53AN P 10 �) Page 9 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSUAFAC11 SEWAGE DISPOSAL. SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address ` Owner: Date of huperilon:— WIL ABSORPTION SYSTEM(SAS):/r (locate on site plan,excavation not required) If SAS not located explain why: `hype !leaching pits,number_ leaching chamber ,naiib—cr: leaching gallcrics,number: _leaching tseaches,number,lon$th _ luching fields,number,dlmensionts:� _ --- avertlow cesspool,number:i imovative/alteruadve system .ryp,/nassne of technology: Commenu(note condition of soft,signs ofhydroulic failure,level orponding,damp soil,condition of vegetation, etc.): / 0 — 'W' CESSPOOLS: (cesspool must be pu sl as part of impecaivst)(lQcate on site plan) Number and configtarativn; Depth—top of liquid to inlet Wwwor Depth of solids layer: Depth of Scum layer. Dimensions of cesspool: Materlafs of comtrucifo Indication of powadw er inflow(yes or no): Comments(note co pion of soil,signs of hydraulic fail((,c,level of pending,condition of vegetation,etc.): PRIVY- (locate on site playa) Materials ofcolimuction: Dimcnsiut+s: Depth of solids; ----- Comments(note condition of 1,signs of hydraulic failme,level of ponding,Condition of vegetation,etc.): Kt1[1 XY3 oZ:Zi 4o/Zo 9009 L FROM :CARMEL-DRIER FAX NO. :5087606644, Jul. 20 2007 09.:54RM P12 ' Pave I 1 of l l OFFICIAL INSPECTION,,FORM-NOT FOR VOLVNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSP;l coon FORM FART C SYSTEM INFORMATION(continued) Propmrty Addreis: e2l Owner: ly llate of Inspection: SITE EXAM slope if 0. SurNee water tAlc Check cellar Shallow wells oil Estimated depth to groundwater feet Please indicate(ehtxk)all methods used to detcnnine the high ground water elevation- _Obtained from system design plans on record-if checked,date of design pi3n reviewed: Observed site(abutting propertylobsorvtttion hale withb!139 feet of SAS) Checked with local Baud of health-explaln:. Checked with local excavators,installers-(attaehacuiiaenwtion) Accessed USGS databaeaaexpialna You Must describe how you 4subtished the hiSh X,round wafer etsvntion: 9 , as 11 XV� T 9T T AGO 9007, I 0-0 No.••••./...� Fss.. : ACOMMONWEALTH OF MASSACHUSETTS BOAR® RF HEA 01 11/11L..... ..0F................. � ........ .................................... Applira#inn -for Bi_qpnsal i0orks Tomitrnrtton Vrrmft j Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal, System at: , 14 r' ��..--t:-2E.T .-- -A rr�� .......................... �'� - -.......-.l1115....... Location•Address or Ijpt Ivo. a-------------- °�°� Z y;R1� °':!_. l ..-- Owner ) _ Address Installer Address �•� dType of Building Size Lot_( ---_G`--`--- -__--Sq. feet U Dwelling—No. of Bedrooms--- ---Ir...... ....... ....Expansion Attic ( ) Garbage Grinder ( ) per, Other—Type of Building ----- No. of persons_.•_________________________ Showers ( ) Cafeteria ( ) a d Or fixtures --------------------------------------------------------------------------------------------------------•-----------•---•---•--•-•----------••-•-•--- W Design Flow...r�o.................................gallons per person per day. Total daily flow__'_&_A�...........................gallons. R: Septic Tank-—Liquid capacity._Vgallons Length---------------- Width................ Diameter---------------- Depth................ Disposal Trench—No. .................... Width------------------- Total Len h_______ Total leaching area--------------------sq. ft. �,�•• ---- ------ - Seepage Pit No...... --.___.. Diameter. _. _ R Total leaching area----------------_sq. ft. z Other Distribution box (')C ) osin nk ( ) ._4'� - .D L, aPercolation Test Results Performed by------- ---------------•----------------------.....----.................. Date---•-•--------------------------------- ,� Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water.....,-----------.-..._. ti Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water-_.-_.---_-.-_-----:-. - t ; - ------- - -------- Description of Soi_.._. 'l� �1. _Coe � ' r �`~ = r✓b -------------- x 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 agrees not to place the system in operation until a Certificate of Compliance has b issuedd by t oard of health. el Si •e `= ••. . ----_-•-------•-------------- A / Date Application Approved By...... .--- •. ... ... . ... '' ''tom. ---------------------- -- Date Application Disapproved for the following reasons:...................... ----------------•-----•-------•------------.....---------------------•--......---•--.... i •---- ------- ------- .te----- -------- Permit No......................................................... Issued...�>--_��__-- �:�..,..-................... P ate LOCATION ` ~) 5EW& E PERMIT UO. VILLAGE IWSTALLER•5 UWE DRESS BUILDER 5 ADDRESS go;F-tv Z,6 ` -® - - Dl�►TE PER"VT ISSUED :�2 (a)-- — D ATE COMPLI W-dCE ISSUED : — — — 30 r 1! ,e ...... FEE.. .�Q THE COMMONWEALTH OF MASSACHUSETTS _. SOAR® F • Apli irtt#ion -fur Di.ivusal Worho Tomitrur#ion Urrmi# - Application is hereby made for a Permit to Construct ( ) or Repair ( }: an Individual Sewage Disposal System at -ffG' f T�Alel................................... ....................................................................................,----------- 11ji0 d fW dq - orro p ------- ---------•------ / -------- Owner Address '------. �. e'-......................•---------------------•--••-----•------ Installer Address Q Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms---------------------------------------------Expansi'orr¢A"ttic (> ) Garbage Grinder ( ) a Other Type of Building _--_____.__-_ ....._... No. of persons___________________ Showers ( ) — Cafeteria ( ) :. _ Q T ' 4 Otl r fixtures - 'P w r ?, , t ____ ________ _________________ _ _ ___}r_ __.....__ _ _______________________________________ "` .Design Flow:.. p p p y y '`� '© g� W j ____ ______________________gallons er erson er da Total da�il flow.....____...__-_______________-___.-.__ . ..gallons. WS trfi� 1 rink J.Ziquid capacity__ ._. allons Length----------- :Width.-____- .--- Diameter................ Depth---------------- Disposal x Trench— o--------------------- Wi th-_--____-_---_-__ Total Len��11 _____ ..�}..�. Total leaching area----------.---------sq. ft. Seepage Pit N'o...._. ______ Diameter_ _Y'.� 7- 1 , ' iKL#d ' _!.r�'l otal leaching area___________--.-_-sq. ft. z Other Distribution box (fit) singt tik ( ) ��r pj. AC�,� J� • /�' 7yo Percolation Test Results Performed by.......................................................................... Date--_.-------_-____.---------.-------- ,� Test Pit No. 1................minutes per inch Depth of Test Pit._............_.._f. Depth to ground water.-._________-:_._-._---. (i, Test Pit No. 2................minutes per inch Depth of Test Pit.________.........i I "th to ground water__._____________-____.-. `'!� n O ' Description a Soi r t. '":.�!�* �. .............. U -------------------------------------- -------•---•----------------------------- �--y-rr--- , ""--•---------....-----------•----•••--•-----•-----•--.._......-•-------..._. .. WM , > & 3f 1a3 ----- •--------•--= U Natu-rc�P TZepaifs or Axerations='Aaacghen 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 Code—The undersigned further.agrees not to place the:"system in operation until a Certificate of Compliance has b issued b t and of health. ( _ 1 • St e } x Date Application Approved By------ f•... ---------------------- �.'��.d....--T!/...---- .' Date t Application Disapproved.for+tlie following reasons:..................................... -----•-------------­• -----------------------------------------................................................................................................................. •. Date PermitNo. ................ Issued.............................z- --------------•--.------ ' A4 Date °P THE CO] WkALTH OF MASSACHUSETTS f - q BOARD Q HEALTH / . ..............O F........ .:. ... ............................... r Apr#ifir�#r �f f��attt�ittnr:e W. L.Of RTPY, That the Individual Sewage Disposal System constructed ( r Repaired' (; ) by.... ...... ----- ------ ------------------------ --- ----- w' ±� stallerhas been installe in accordance w he provisions of Article I OL�sThe State Sanitary,Codejas-described in the application.for Disposal Works Construction Permit No--------- oof................ dated.'- ........... THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS A GUARANTEE THAT THE ✓'} SYSTEM WiLL'FUNCTION SATISFACTORY.. 'u DATE. ------...... Inspector - -= ' THE COMMONWEALT-H,°OF MASSACHUSETTS BOARrb _'OVj HEALT .. OF �j r NO-:.... ..- :y ..... r FEE.-f-.f .... Perm' Sion is re granted 0 +._. ..,.. .---------•--•............ =...... to Cos ct °or Repair an Individual wa isp a System ✓ '- atNod•• � ',5 r ................................................... .. .._ Street � 7 as shown on the application for Disposal orks Constructiorif.P t.N ._ _. .__ Dated__01 ___ ___________________________________ i� :Y Board of Healt DATE::, , ,FORM 1 S HOBBS & WARREN. INC.. PUBLISHERS - - - - - (TEN R RL NOTES \ F11,15VIcf Grade �Mloi-t\-,o\- (--oJCr bro�`-+T Qv:,--o \2' o4 \i--,r„bt^, �r..le— , i\V/.,lJ r77�\7 - 77 7/JJ�T�TTJ���7i���R7-TT'Ct-�7i7J7��CT�J I, �� iJ C«7!f„ 77 ��JGC g�r,c t"7 «1o1'K 4r� P\OT P\an� L-Oc4TQ0 -:-- TeeT� or-rr>'e \r, gccoc- o�r,cv w T�, ��a \ 4, �. 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