Loading...
HomeMy WebLinkAbout0056 ALLAN ROAD - Health 56 Allan Road I Centerville A = 194 - 001 - 010 ` tb UPC 12534 No.2-153LOR ' HASTINGS,MN d M s i j 19V. JIJA/ 09 11 601 0/0 2 5 BORTOLOTTI:CONSTRUCTION,INC; nFB�Rti 9Q� 765 WAKEBY ROAD,MARSTONS MILLS,MA ,112648 r"�FPTr98�f 508-771-9399 509 4284926 FAX: 508428-9399. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPE1QTXgN,FORM Of 6 PART A.. r ;` �: •< CERTIFICATION- Property Address: F { Date of Inspection: Ins is Name: is Name and ddress: ON - ! I certify"I,have;personally inspected the sewage disposal system at,this.address.and,4hat;the utforata- tion reported below is true,accurate and complete.as,of the,time of inspection.The inspectioawas per formed based on my training and experience in the properTunction and maintenance of on-sltesewag- disposal stems. The System: Passes , • . Conditionally Passes ,' Needs Further Ev o y e Local Aproving Authority Fails '- P ti Inspector's Signature: The System lnepector s 1 submit a copy of thus inspection-report to,the,App.ovin au, on within S� � .ty 4htr- tY,P, %days of,completing this inspection. If the system is.a shared system or has a design;fl of.10,000 gpd:`or greater,the inspector and the system owner shall submit the report to the a�propr ate regional+. , offtce.of;th;Repartment of Environmental Protection.,The original,should:be sent•.to,tlte,syp owner and copies sent to the buyer, if applicable and the'approving rovin authority. P Y PP PP g Y �i$PECTION CiIMMARY• A)��SYST}C1YI PASSES: .; f ? t/ ;I have not found any information which indicates that the system viplates atiy of the failttre t; criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated,are:indicated .below. B)SYSTE CONDITIONALLY PASSES One Or-,more system components;need to be replaced or repaired.•,•The systept upon comple lion of the replacement or repair,passes inspection. }p Indicate yes,nor for not determined(Y,N,OR ND).Describe basis of determtn,aticin to lhall instances If"not detertnipW,explain,why not. Fa The septic tank is metal,cracked,structurally unsound,stows sub,tautttal itt> Itration or. -w lexfiltration,or tank failure is imminent.—The system:will pass;gns ects0tt if . -1— . ,tte tank is replaced with a conforming septic tank as approved by Tho,Doerd f Hj _Sewage backkup or breakout or high static water,level'observed J n tt e,d�.atribµtion box_is due { to broken or obstructed pipe(s)or due to a broken,settled or unevein'distribution box. The ;system will pass inspection if(with approval of The Board of Health): • -1 ! a ;i I `ve'��'+ ;'vw ;, 'a .,taw -..+�.Js -T%s.;:i3" 'v'��;r e t>_ r.,.".a X'l�v' a r`E"'.A r.. °s .+c•v `.,n 11 FIRM v dl v r� ;+ � 1�a �X7�� 'f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Brokc pipe(s)replaced j 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 pipes)are replaced '. _ i r _Obstruction s removed C)-FURT#ER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH. � 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 envir'onnient: "i w 11)•SYSTEM`WILL PASS UNLESS BOARD`OF HEALTH DETERMINES TEE AT THE ':SYSTEM"IS NOTIFUNCTIONING IN A`MANNER'WHICH WILL PROTECT THE`'y ' �A PUBLIC HEAI,THND SAFETY AND THE ENVIRONMENT: ! ` Cesspool or privy is within 50 Feet of a surface water , ` Cesspoolor privy is within 50 Feet of a bordering vegetated wetland or a•saltx ,marsh= - p ,'Y 2)SYSTEM WILL;FAIL UNLESS THE BOARD OF HE (AlY®PiIBI:i<C'WATER .i SUPPLIER,IF 40ROPRIATE)DETERMINES 7THAT THE SYS'I�1ht`IS FUNCTION ING IN A4MANNERTHAT PROTECT THE PUBLIC HEAL`I'.H'ANfD SAF'ETYAND THE 't ENVIRONMENT:. . The system has a septic Uwk a. soil absorption system°anti is w�ithil► lOQ Feet to a surface water.SUP ' or tributary to a surface water supply. ' The system;has a septic tank and soil absorption system and is with ago e I of a" ublic"rJ I water supl ly well. i;"`The system has aseptic tank and soil absorption system and is within 50`Feet of a private "� ' water supply well , '. +r44 , The system has a septic tank and soil absorption system and is less than 00 Feet but 50 T d Feet or more from a private water supply well,uriless a well wateesn81 t fo oolifomu 'r ' �? bacteria and volatile organic compounds indicates that the well is free,from pollution from the facility'and the presence:of ammotua.nitrogen and nitrate iltrogen s equal to orless^ °a than 5 ppm. D)�YSTEM FAILS:' . , .. F I hove determined that the system violates one or more of the following failure criteria as daLitied in:310 CMR 15.303. The basis for this determination is identified help-#. $Tlte Hoard of Iieelth ' si ould be contacted to determine what will be necessary to c,o t the failure, a w k2- -it l Backup of sewage into facility or system'component due ttj a.n'overloaded or clogged;SAS or cesspool. a t, Discharge or ponding of efluent 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 ur Overloadeyd or 0511.1 J ged SAS,or cesspool. ti r7` Liquid depth in cesspool is less than 6"below invert or available volume is less than.1/2 � day flow.`' , . - • ,:, . ., I ,�°'� t diae to clogged or'obstructed i Required,pumping more than 4 times in the last year I�QT i pipe(s). Number of times pumped -2- t a ri e _ I m t i 3ItBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) ' "L� � +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 conform bacteria,yolatile organic compounds,ammonia nitrogen and nitrate nitrogen. t aT E)LARGE SYSTEN FAILS: � •: _,: , :: ,The following criteria apply to a large system in addition to.the criteria aboyetr, tJ i{�� .. -. y t,•.,j The'desi flow of a stem is 10 000 or realer e System)and'the' is a ! :. p , system 6Pd g (fig Y ), system 8igniflcant threat to`public health and safety and the environment because one or'imore'of the following i Yl conditions e4st The,sy�tam is within 400 Feet of a surface drinking water supply ti � �tks s ! "The system is within 200 Feet of a tributary to a surface drinking watert uppW°.F' r The system,is l9cated in a nitrogen sensitive area Interim,.Wellhead Prot4"n'Area I°l' +. (IWPA)or'a'mapped Zorie II of a public water supply welds `< y Tie owne}'jor operator.ofany,such system shall bring the system and facility'iito hill ogmphance a!tthgtho groundwater treatme. program requirements of 314 CMR 5.00 and 6.00:'Please ootts4lt'the'local regional o)ice of the Department for further information. f t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 4.1 PART B CHECKLIST jid' . ♦ e . - ,-. �T •_ {Y k'2i i� i a py,•5 �:',�'f Yl,I;• Chick if. ollowing have been done: t __ information was requested.of the owner,occupant,,and Board of Health . t4 ` one.of the system components have been pumped for atleast two wmU'and"thefsystetn"ha6141 been receiving normal flow rates during that period'Largivolumes'of watef have"ram 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 a�iailabte with N/A.w facility or dwelling was inspected for signs of sewage back-up system does not receive non-sanitary:or industrial waste flow.,s v ' elite Wa$inspected for-sips of breakout. _�P►q system.00mponents,excluding the Soil Absorption System,have septic tank`manholes were uncovered,opened,,.and'the interior of.the`Sep tank wes t'y° ' spected foroondition of baftles.or,.tees;material of construction,dintensionatj fdepth' ll ' t, epth of sludge,depth of scum, ,, 3p;,;> ,¢f'=,, 3: a ^ �t '�� , sr„� .,. The size'and location of the Soil Absorption System on the site has ban deternrtined based on' j existing information or approximated by non-intrusive methods. -3- f ,.i ♦.r q: 'a 'i�. :- x ' �`i -r.- , �� w`�'if.a•e rr��r. *'t�^��•;�ro '•'' �piA'f �yn I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST(continued) —The.facility owner(and occupants,if different from owner)were provided with information on the proper.maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL SYSTEM,INMSPECTION FORM PART.C- ti SYSTEM INFORMATION FLOW CONDITIONS , RaSM 1Nn V / 'f wS # I'•:7' t Jar l2 Design Flow: 1}: i tons Number of Bedrooms: Number of Curremt Residents., Garbage Grinder: Laundry Connected To System e.10a Seasonal f Water Meter if lable: ,• LastDate;of..Oc upancy. ' CJ Type of Establishment._'." : Design>Flow k.'- tealIonstday Grease Trap Present: (yes or no) Industrial,Waste Holding Tank Present: Ton-SanitaryWaste Discharged To The Title V System: _ Water Meter:Readings,'If Available: Last Date of Occupancy - . OTHER; Describe) 'Last Date;of Occupancy: GENE INFORMATION &WING RECORDS and source of inform tion: v. a� System Pumped as part of inspection: if yes,Zolume pumped _ r: Reason for pumping: TYPE YSTEM: F V'Septic Tank/Distribution Box/Soil Absorption System :r SiqglC OvertlowwCCesspaol I Shared System(If yes,attach previous inspection records,if any) Other(explain): W-,j t OXIMA Awh ll components,''date installed(if k n) d sourcr of µtformation: ` Ifi Sewage odors detecarriving at the site: s a r ,, _4_ 4„ i 4� �1 I 'I Wr SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C GENERAL INFORMATION (continued) SEPTIC TANK: v ( J Depth belopv grade Material of Construction: li concrete metal FRP; i Other ti (gyp )' Dimisions:: .S' ' Slud a De the 11 '' g P _Scum Thicl�ness. Distamm,from.top of sludge to bottom of outlet tee or baffle: 36 Distance from bottom"Of scuin to bottom of outlet tee or baffle: 'all 11 Comments (recouumendation for pumping;condition of inlet and outlet tees or, pth ofllquid' level in" , �tion"to `det invert structural inte Brig+ avid nee of leakaUdage,etc.) 150"74 Jr. GREASE'WRAP:" Depth Below Grade Material of Construction:' concrete metal 4` FRP_Other; ,;$ (explain) y Dimensions: Scum Thickness:) Distance from top of scum to top of outlet tee or battle: >. ; :comments i(recommendation for pumping,condition of inlet and outlet tees or bales; epth,of liquida level in ref on to outlet invert, structural integrity,eAdence,or leakage,etc.) '''''zeta, �'''°"�7 7 TIGHT,"OR HOLDING TANK: Depth Belo p Grade: Material of Construction:_concrete metalll+RP_Qther(explalm) ltmensto ,.. g Design ttallotts/day �i Capacity: allons Desi Flow: '.Alarm Level: r Cgptments:l(condition of inlet tee,condition of alarm and float switches,etc.).' "` DLSTkmupnoN BOX: Depth,of liquid level above outlet invert: Comments:.(note if lev, and istribution is equal,'eviden f solids carryover,evil ce`of 1 or o of boil,etc.) Aj PUMP CHAMBERi_ PUMPis in•workin._. _ _. . g order' . Comments: (note condition of pump chamber;condition of pumps and appurtenances,etc'J i -5- i 1 i n.tL.r. r, w N t SUDSURFACE SEWAGE DISPOSS T SYSTEM INSPECTIQN FORM PARj• SYSTEM INFORMATION(continued) j; SOII!ABSORPTIO�t SYSTEM(SAS): Y' f (Locate o 'Bite plan,if possible;excavation not required,but may approximated by pon-intrusivei f } methods)If not determined to be present,explain: ' �I do {',!•s. - -" ..... . a .:"} :.. 'yin IG ._"'•n. Nf r X Y Leas 8 Pits,number: Leaching chambers,number: Leaching gallefies,number a f Leas trenches,number,length: Lending fields;number,dimensions: .::— Ovel f oesspoo, umber: Comments:(note condition of soil,signs of lay ulic lure level f ponding,' n tign+o vegetation, etc .i .,iiw _ 75 ...'r. u CESSPOQLS: S Nuinbe and configuration: Depth-top.of liquid to inlet. Depth'of Aida layer:' Depth of scum layer: Dhneniiwis of'esspool Materials of construction: Indication o�oundwt<,ter:_, Inflow(cesspool must be pumped as part of inspection) Comments:(note condition of soilk,signs of hydraulic failure,level of ponding,a nd�tion ofvxegetationm +, etc. ; r 1< 4 atgd:r�3,' 1 RIVY: a' 4 t + o2k"q N4� • terials'ofconstruction: e Dimensions:_ th;of Solids: -- - . Co nts,(note condition of soil,signs of hydraulic failure,level of po�►dutg,cor�dit on`of vegetatiapar i y r etc.) 2. . r -6- :s • I f 7 - I i ;;..SUBSURFACE SEWAGE DISPOSAL SYSTEM L'�OEd:rION FORM PART C SYSTEM INFORMATION(contin4ed) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references, landmarks or benchanarks. Locate all wells within 100 Feet. .aP/(� T _... 1 1 � > s , DEPTH TO GROUNDWATER: Depth to groundwater: 3� Feet l ,, oDetrmination or Ap roxi lion: 7 0 ' . s i -7- r No...... THE COMMONWEALTH OF MASSACHUSETTS BOARD F HE-ALTH ....0j.0...............OF....:. .......................r4.10..le....................... Appliration for Dhipaaal Works Tonstrurtion tirrmit oeu Lr7P, Application is hereby made for a Permit to Construct or Repair Individual Sewage Disposal Systesff-aff!'*��.__ �..n/....................... A . .................... f— .//----- -----------' mod . 7 t, Add or Lot No. E2:5Z;.................................. -----------.......................... .......................................................... owner Addr......... ....................................... .P Installer Address U Type of Buildi6g Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder Other—Type of Building ............................ No. of persons_...........__..._......___. Showers Cafeteria Other fixtures Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 9 Septic Tank—Liquid capacity............gallons Length................ Width......__-_....._ Diameter_______......... Depth....._........_. Disposal Trench—No. .................... Width............__...... Total Length.__......_.......... Total leaching area--------_--_----sq. f t. Seepage Pit No____________________ Diameter.._.._..._._........ Depth below inlet..............._._.. Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ 4 Test Pit No. 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......_............._... 0 P4 .......................------------- ....................................................................................................................... Description of Soil......................................................................................................................................................................... �4 U ......................................................................................................................................................................................................... ....................... ................................................................................... .......4-------tl....I............. ............ Nature.9�fRepaiirs rAlterations—A ey, when applicable..- 6__ . r U Alsw 1. . .......7...... ............ ......................................................... ........................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'I'LE, 5 of the State Sanitary Code— The undersigned further agrees not to place the system in 'L operation until a Certificate of Compliance has.be b theb rd of health. -- Sig . ... ...... .. . ...... ........... ... ...................... Q�m Y,9 ............... Application Approved By..... Date . . ...... .. . ................................................ ....... 2.,j--�.ge....... Date Application Disapproved for the following reasons:..................................................................... .......................................... ........................................................................................................................................................................................................ Daft PermitNo..ef ------------------------------ Issued....................................................... Date No......:..:�....... :... FE$.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD--OF' HEALTH, ................. ...OF. ..'.(..... . f Appilratiou for Bispoottl Works Toostrortion ramit Application is hereby made for a Permit to Construct ( ) or Repair (*/-Jan Individual Sewage Disposal System o r ,.. f f '�i`7 tit r"......... .......... C. !�: f r r� " / l %J "_ .... C� 1 I�, � /a t ••• ,4ocation-Address - or Lot No. ..� _j... : fF.�:d;'.�.................._� I................................... . .......................................................... f la / Owner, Address ..................................... ..............: ......................................... .... '.-........•f..7 � - ---.. ............................. Installer � -Zr y 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 --------------•-•-----------------•-•--------------................................................................................................... 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 ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ fs, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water_-_-•_--___-____-----_-_ t4 •----------------------------------------•----............................................................................................................. 0 Description of Soil.........................................................................................................................................................---------••-•- U •-••--••••••---••-•••----•--•-------•-•.....--•------•-•-----•---•--•-••-••-•......-•---•......•••••--•....-••--•••-•-•----••-••-••---•-•-•-••----•-................................................... ...................................................................................................................................J__.._ -------------- .._._ .._......._.____.._.______... U Nature o Repairs,pr�Alterations—Answer whenrapplicable._� f.'.._.'-�a-l-.�._�_____________ `" � ° ..:__.' ..% f Agreement: The undersigned agrees to install the aforedeseribed Individual Sewage Disposal System in accordance with the provisions of TITIE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issu d by'Ae board of health. ,r Application Approved By----•./-,! '?, !i� e,_ C.. 4 ^^• 1-1 Datef.._.._. -. Date Application Disapproved for the following reasons:..................................... ------------------•----------------------.......................... .....................................................................................................................................•-----•---•-•-••-------------•-•--• ............................... Date Permit No..,. '" 6 . `' Issued. f., ;.2................ ......................-- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD, OF HEA TH (9rdifiratr of Tootpliana THIS LSTQ-CERTIFY, Tat they Inddual Sewage Disposal System constructed ( ) or Repaired(� by-.---f/f t .f'"" .........__Installer f/ at...... I?..._. .---- "" "J ............ has been installed in accordance with the provisions of TImIZ 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.... _ .......... .. d-ated_...,f ; - __ ................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CON RU D AS A A ANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE �(�.. _............................. Inspector -.....`�----�--------- ------- . ------••--•-••--•-•-•--- THE COMMONWEALTH OF MASSACHUSETTS BOARD,,.-OF HEALTH ..................... .OF...:e d d/, a r�l .............................. _ (�1 ;✓ ............. .................... (� No................ ..i::>' FEE....................... Disposal Work, �000rtioxt. rroti Permission is hereby `_. / '. 'r ..Viz. _ . . -- -----------------•----•-•-------.....•••..........._........ to Construct ) or Repair (°''�) an Individual Sewage Disposal System i r � Z_,._....----�,- 40 ................................................... reet as shown on the application for Disposal Works Construction Permit No,�&- =- _ Dated-___�. . �:.�..._.__/---'.-_-------- -••-••---•-.......--•----•-•------•••------------------••----------•••••••--••••-•-••••-•-••--------•••-- ......'-_.--...•..--•....... Board of Health DATE........................................._:...... FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS �"� O OF BA N TABLE �d LOCATION SEWAGE # S VILLAGE P1� - ASSESSOR'S MAP & LOT t "l \O INSTALLER'S NAME 6i PHONE NO SEPTIC TANK CAPACITY 02. lij •`s " LEACHING FACILITY:(type) 6 _�U�BLIC(NO. OF BEDROOMS PRIVA E WELL OR WATER BUILDER OR OWNER j %JO ?DATE PERMIT ISSUED: DATE COUPLIANCE ISSUED: VARIANCE GRANTED: Yes No �� r iy 3 Ile /% IS : THE COMMONWEALTH OF MASSACHUSETTS 7�0nBOAR® ®F HE LT .... ----- OF.............Bar l'l S�l..b�f'........................ , pplir�ation for lliipusFal Works C ontitrurtiurt ramit Application is hereby made for a Permit to Construct (✓) or Repair ( ) an Individual Sewage Disposal System at: + o f 1 Q CL 1 I an �f e 11�r V I 1 )e- ................__--- - ------------------ ------------------------ i ......--------•------...------...... ......---- Lo: r d e r No. 11 TT' . .................. ....................t --------------------•-•----....------------ --- . ...... .... Installer Address /i/� O f UType of Building �,Q Size Lot................ ..........Sq. feet �., Dwelling—No. of Bedrooms... _---••--.._ _ ................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ...�.6-&__.... No. of persons............................ Showers ( ) Cafeteria ( ) a Other fixtures es ---•-•-----•-•-•----••-•---••••.... Design Flow.................... .................gallons per person er Total dai flo 3.5-.................... WSeptic Tank—Liquid capacity.._...._...gallons Length________________�JVidth__._ .Q'.�iameter___-_._......... Depth_. �.� x Disposal Trench—No..................... Width . _.___..... Total Length.................... Total.leaching area....................sq. ft. Seepage Pit No..................... Diameter..__.._`i� . Depth below inlet......L.......... Total leaching area...s3_Z�......sq. ft. Other Z Pe colation Distribution Resu?0-4 Performed by to �kacph ��.......................... Date_._.__. .__.�.�-._.�-`. .___. Test Pit No. I................mmutesperinch Depth of Test Pit.......&........ Depth to ground water........f�......_.. 44 Test Pit No. 2--L 2--_-.minutes per inch Depth of Test Pit.................... Depth to ground water........................ -----------------r •-•...-•-------------. -•- - + O Descr' tion of Soil s = o "21, �. bam G 6..._��.L� -,g....Z" - x - - UW -•--••-•--•--------------------------••----•-----------------------•--•----------------•--•--•.......... . ---------------------------------------------------------------------- Nature of Repairs or Alterations—Answer w en applicable_ S ................................................................. !!fir �� � .r( RWv -'� �-A-r�s��J i ---------- 7 4�------------- Agreement: )A7 w(211 I N G falj�-T e=A/- +"a& _0 A5 OL-FoWz1jJ re undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the siol of MIT 5 the State Sanitary Code—The undersigned further agrees not to place the system in o era • n til f Compliance has been issued bby th ard-of heal h SignedT MC / G j Appli tion Approved BY "%'° -•-------------------------------••-••. I/� Date �y ieation Disapproved for the following reasons--------------------------------------------------------•---•-------------•--••-••---------• --••---•-•--....... ................•---••---.......---•----......_.....---------......_.....-••-----•---........--•-•-......-•---•-••-•---••-•------------••-•-----•---•-•-------------------•-•----------•---•--•-•---•--- Date —Permit No------------------------•----•-.-----------a --•---... Issued....................................................... Date --------------- ----------------------- -- i s a THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF............ ....... .................. .............. Appliration for Disposal Works Tonstrnrtion Prrmit Application is hereby made for`a Permit to Construct (✓ ) or Repair ( ) an Individual Sewage Disposal System at' Lot Lol I Li c � I cl I^1 ��� _1� � ! 1 � �( V � 1 Lo .ion. da.�ess .. .................... .ht.No. L •.-•••-•-•.....� �CL C.k......t.1 l:�,l t•C ? .......... --• --•- •J� . [� X S _a _. .C i . C� Owner ddress W =••1 ���� _..... �_._.....�...•...---^-^..... .J.................................................................... � a Installer JJ A Address Type of Building -�"" Size Lot..1l...._....•._.......Sq. feet .(- Dwelling—No. of Bedrooms...................(� :.._..._..........Expansion Attic ( ) Garbage Grinder ( ) PL4 Other—Type of Building ...... No, of persons............................ Showers ( ) — Cafeteria ( ) 0.1 Other fixtures -------------------------------•------------•-----•-----•-•----•-•-------••••---•••-......-••--••-•••-•-•-•••----•---•••-•-•--•-•----•-•••......--•-•- W Design Flow..................�S..........:......_gallons per person per ...a.y.Jotal dy' fll.o. � >d->............................. Tank—Liquid*caPacitY!©Qc _gallons Length....:...... � ....... Diameter................ D ePth..:...�...l..�...a..�n x Disposal Trench— o..................... Width_....__......._..._ Total Length.__........�---.--- Total leaching area.... ._ sq. ft. Seepage Pit No_____________________ Diameter....._. 4.._ Depth below inlet._............... Total leaching area. ._:._._sq. ft. Z Other Distribution box (✓) Dosing tank j ,11 '-' Percolation Test Resu is Performed by �`" O E/jo C_ t<�l r . � � W- - --------------------•--------------- Date a Test Pit No. 1-------z-:....minutes per inch Depth of Test Pit....IL.......... Depth to ground water-------L�_-___-_--. 44 Test Pit No. 2..L.2.....minutes per inch Depth of Test Pit.................... Depth to ground water........................ w ._......_...�.......... ........................._._....... _ ----- �../__.._ ....................... O Description of Soil_.._�_L....-•-P(..................-----� .. 2 z. 1"C)Ct r Y 1 Ct t i!( �1.1 �� D �f � � �U � Z. ---.—�.1c z = c. � � cE ..= -�.----. —-------------------------------------------------------------------------------- W -•-•-------•-- -•--•--•---------•-•---•---•-----•----- -•-•------•------------------•. - V ature of Repairs or Alte ations Answer mh n agplwablg .............. ----- "V . t , fws i Agreement: t ..� �� h undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with th pro isio��s o TI 'f the State Sanitary Code— The undersigned further agrees not to place the'system in per ionntil of Compliance has been issued b, th -board of heal h: r-- .. Si named-----...------------------------------------------------------------------------------- ........................... A cation Approved B PP PP Y =' ---................................................ .. Date 1)lpplication Disapproved for the following reasons----------------•---------•-••---•----------------------•---••--------------------------------•-----------••••••. ................••-•••••--•---•-•-•--••-•-•----•.....----••••----•--••-•---•----••-•••-------•••-•----------•---•---•-----•---•-•----•••••------...••----•-••--•-•------•--•---••-------••-••-••-•--•--- Date PermitNo..................................................I Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS �-�rtx�l N t5�I;- BOARD OF HEALTH .........................................OF............60- 1 ) / .....................`......................................... CIntifiratr of Tontplianrr THIS JI T CERTIFY, Th t the Indivi al Sewage Disposal System constructed (✓) or Repaired ( ) UC,L C 1t��1� �..U.y..�':....�------------------------------•---------------. `—0� /V C�i.'t- ��� r��G( Installer ( � �� � = r �� L 1 at -•---•-------------------•--•••-------------------------------------------------------- has been installed in accordance with the provisions of TIT 4-rj of Th Staate Sanitary C��e 2� `c�ribed in the application for Disposal Works Construction Permit No........................................ dated---------- --.-___/-�:._____............_... TIME ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector................................................................................... THE COMMONWEALTH OF MASSACHU4eMC94AIINS �- - BOARD OF HEALTH tvtvsr r ............................................... No. ...._ i FEE........................ Disposal Works Tos# ion rrnitnr -Permission is hereby granted.. :t---- . ---- ----------------•--------•---..------.--..-.---.--.---- toIndividual .... Construct (✓) or Repair ( an,•Individual,Sevyage Disposal -ystem at No..--••- ' ----••!•2.....• .(••��. 1�. C`!'. L(=.0 1-----....%.... --.-��... Street l r ... as shown on the application for Disposal Works Constructior�rmit No.'._._-�__..��-�_.'SDated............X .... ................•--- •-•---•-•-•--•--•---•-•- a ! —2 Board of Health DATE............1......................................... •--••---------------- S FORM 1255 A. M. SULKIN, INC., BOSTONI , - j lz 3 4 " F�vsof 464 " 4 "v: e O r i A -r� 3 t'K'4•�1;ck ti"" /T , 4 5 ti/TA 4 E r OF i �a'k°.y7�, y + ..y.A�#ah'A.`. i �F qt y r. ti �.k • +:r� i� r k s x 4` r•* ACBERT-s.; �N A Q 't 4 1 :, s Y.+A•.r 3 t t,� _ � Na 1095 ry$ � c_aty ' N a ��� t • �,,.�* � a .,, x'c_ 5 d /. � - s ` C9�7ks� N LEGEND'. 4 AEXISTINGt�aS,POT' ELE,VATIOI� of A µ CERTIFIED PLOT PLAN sEXiS'fING ''C.ON.TOUR`-= ® a �a�pti, r 49ssq f . / rF,off Arc �V �. {FINI;SFiEDr,SPOT ELEVATION 5Y afROSE �r s FIIdISHEO w:CON:TOUR T-- O L.E JAPPROVED.= 80ARQ . OF HE LT H oR, No 519367 H t} t''�, £GrSTE�'� �� L.Lazo es' rA,`D E �., AGENT x SCALE] n_ 40 ' DATE ,ry J /G L.pREDGE.:ENGINEER/NG: CO IN CLIENT*,' . I CERTIFY THAT THE PROPOSED Y r { f EGISTERE °j 'REGISTERED; ' �� ,, ,,� , JOBvNO ��g�� BUILDING SHOWN ON THIS PLAN . CIVIL LAND ` DR,BY•' CONFORMS TO THE ZONING LAWS s " ENGINEER SURVEYOR , _, , OF ' BARNSTABL MASS. A, 712MAI N ,STREET * CHa`BY= •;. N:Y A N N I S MASS fi °�: Z• --- �- a', w f ,• ' 3 . SHEET..!.OF A E REG. LAND SURVEYOR 7f ( ff s.2 ___ .�_.....I _`yF� c t•, st FIy, r^ s , % _,` -.y }. g. \ iy t rz+' ry a:Ln ;h•''� v O ~ f i p , lk �l \ � \ � � ` ♦ 1 � V � '.I.. V.1',r ` ..4 k�f V 1. Y �MeM Y\�t�� "�'1 �Y rv' �'-';. � t��f�� ���.- Ito" 6 N.y+�a3�Yt ..+Z, wad Jh W O Se -i f it 44, i O V v :S > o '... 41 •i• 4 �. ` r; %� ZIP'r ^�i �v (\� `ice V Ati t }a. � W U4oQ4 L R w lhcy b � hto �'a• �:r � Aga Ir `Oy `• V v1 u U =• \ I '.O + 4 r�"ii: ^g„ t'r:j. - AK Y Ij lk 71 41 AV pj ZZ Lu CK tj 14 • {� t an se,*:b+ G� M y �\ T + C c.,mp 1 e.t Q d by H I GH GROU14D WA7 ER LEVEL COMt'U1 A- I OtJ Site Location: L_LA,N R0Ar;:D CE/✓T4._V s Owner: _ Address -- --'— ----- AddEess;A. Notes ---- —�._._— ---- ------ - ' STEP. 1 Measure depth .to water table 7' to neares.t`: l/10. ft: • . mot' _ nh . date is} 77777 :Kt ,STEP 2 ,;Using Water-Level Range",Zone £ and• I ndex We l 1 Map .locate 'site` an,d. determine x t '2- index we.] Appropriate ' dl `rr , �¢ a , t B) Water rang 1,,evel' : e zone ✓` in `STEP ; 3 Using month 1 y reportl"Cur .rent Water ,Resources: C.ond i,t i an w determiner current depth to �� € `water level fore index well T` 8 €T f' y - •mo y r � STEP = t► Using Tab a of Water-level Adjustments for, index well �STEP. 2A ," current kdi'pth to -wafer level for; index well.x ass k :spy (STEP' 3).;:`and water^level ` € zone (STEP, 2B) :determin IY Of] ., Water-1'evel adjustment E . . . . . . STEP 5 ` Est inate depth to-- h i gh water by 'sub_tra:cting the ,water op level. adjus,tmen.t (STEP 4).r , from measured depth .to water ' � i1'evel -at s i:'te (STEP l) . . . . . . _ : . . . . . ���•�.r'0S''4r q4 F� �M g ' ,. - Ir t, k r1�a x F 4T �' i. 2 x - - �°'' R'"'eS M '• `}r``-i 4 y .,t.!'i: r£+�:s'7€'•' }y :yP - + ,.€k' i :.h7ti♦ t t u'�-}, i.ttr.as i. jA- L r President: , Member of: , ROBERT BRUCE ELDREDGE,R.L.S. VEYORS 6Ti �j �j �j CAPE COD SOCIETY OF PROFESSIONAL. y ��' ELDREDGE, ENGINEERING. .'. � ,. ASS:ASSOC.EERS O LAND AND SURVEYORS . MASS:ASSOC.OF LAND"SURVEYORS - Associates: - AND CIVIL ENGINEERS - A!BERT A.MORSE.P.E.,R.L.S. COMPANY, INC. PHILIP WEINBERG.P.E.,R.L.S. .- " _ - AMERICAN CONGRESS ON SURVEYING AND MAPPING Q / AMERICAN SOCIETY FOR CJ\e9 istctz GRC9isfeu / TESTING AND IMATEOIALS -'and tniviL 712 MAIN STREET �utvcyots I� 1 �nylncc ca HYANNIS,MASS,02601 TtL.(617)775.2244 Dec. 27 , 1985 Board of Health Town Office. 2(i7 Main Street Hyannis, Ma. 02601 Re: McKeon Custom Design. Lot .10A Allan Road, Centerville, Ma. Job No. 84067 Gentlemen: A final inspection was made on Dec. 26, 1985 and the results are as follows: DESIGN AS BUILT Inv. at foundation Elev. - 128. 1 Elev. 128 .8 Inv. at Septic Tank Inlet 127 .9 128.6 Inv. at Septic Tank Outlet .127.7 " " 128.3 Inv, at Dist. Box Inlet 127.5 128.2 Inv. at Dist. Box Outlet 127.4 " 128.0 Inv. at Leaching Galley " 127 .2 " 127.8 The system appears to have been installed substantially in r conformance to the minimum design standards specified in our sewerage plan dated 9/16/85, revised 11 /13/85. Sinderely, Eldredge Engineering Company, Inc. Robert "B. Eldredge, R. L. S. President RBE/j ne LOCATIO � , SEWAGE PERMIT NO. VILLAGE INSTALLER'S NAME&ADDRESS 0 BUILDER OR OWNER DATE PERMIT ISSUED 1 Z- DATE COMP LANCE ISSUED 1