HomeMy WebLinkAbout0378 AMES WAY - Health J378 Ames Way, Centerville
Rn tik a TO
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UPC 12534
No.2-1153 OR �
MA�TINO• YN
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Commonwealth of Massachusetts tit
Executive Office of Environmental Affairs PFCF9 w
De artment of
'� SEP p 1997
Environmental Protection t 01%0Fg
Ga THDE.piABtE
Wllllam F.Weld 4
Governor
Trudy Coxe j
Secretary,ECEA / li
David B. Struhs
Commissioner
l SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
Ila—
S�,.r\ � �n e� CERTIFICATION
Property Address: \ Address of Owner:
Date of Inspection: 5CP a� (If different)
Name of Inspector: 13t`vCe \ k0-0—00.Ak.S tar
Company Name, Address and Telephone Number: Is r-clv C� `•
CERTIFICATION STATEMENT Q A, iL oa6SS
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:
asses
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature; Date: /9
eV-.L
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 tc. the system owner and copies sent to the buyer, if applicable and the approving authora�.
INSPECTION SUMMARY:
Check A, B, C, or D:
Al 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.
BI 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 exfiltration, or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as
approved by the Board of Health.
(revised 8/15/95)
One Winter Street a Boston,Massachusetts 02108 • FAX(617)556-1049 a Telephone(617)292-55W
0 Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property
Owner:
Date of Insp :?ion:
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(s) are replaced
obstruction is removed
C) FURTHER 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 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 cvstem has a septic tank and soa absorption system and is within 100 feet lu a wrface wale supply or tributary to a
surface water supply.
_ The wsten, 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 coliform bacteria and volatile organic compounds indicates that the well is
free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5
ppm•
D) SYSTEM FAILS:
_ 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.
(revised 8/15/95) 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 1-1 a Vi m es W A-
Owner: DR,
Date of Inspection: S L0T, QL
D) SYSTEM FAILS (continued):
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 times 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.
EI LARGF SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
The design flog, of system is 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 8/15/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
Owner:
Date of Inspection:
See
Check if the following have been done:
Pumping information was requested of the owner, occupant, and Board of Health.
one 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.
4Z As built plans have been obtained and examined. Note if they are not available with N/A.
j,L"T—he facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow
_L/'The site was inspected for signs of breakout.
jZ—All system components, excluding the Soil Absorption System, have been located on the site.
Z—The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or
/tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
✓ The size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated b\ non-intrusive methods.
.jZ—Thr facilii� o„r,c: (a:.d r,C::par.ts, if differe;:: fro^, owner! were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 8/15/95) 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
3-7 >3 Am4--� W(� Cen�erv.`�c
Property Address: ,—
Owner: tea.
Date of Inspection: J
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 330 gallons
Number of bedrooms: 19
Number of current residents:.
Garbage grinder (yes or no):_A(C
Laundry connected to system (yes or no)..%A
Seasonal use (yes or no):_O
Water meter readings, if available: N�A
Last date of occupancy: 0M G o-,13
COMMERCIAUINDUSTRIAL:
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
PUMPING RECORDS and source of information: ,
System pumped as part of inspection: (yes or no)_
If yes, volume pumped gallons
Reason for pumping.
TYPE 9F SYSTEM
1/ Septic tank/distribution box/soil 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 known) and source of information: '71I t%lle 5-/977 / T6Gv/t /Pecb2�
Sewage odors detected when arriving at the site: (yes or no) (�
(revised 8/15/95) 5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
1 SYSTEM INFORMATION (continued)
Property Address: m es w(13 — Ce;t�eta.'J/G
Owner: 13\ 2. cShIA 13 C�,Ae'
Date of Inspection:
SEPTIC TANK:_
(locate on site plan)
Depth below grade: FT
Material of construction: Zncrete _metal _FRP _other(explain)
Dimensions:
^ O
Sludge depth:,-
JAI-Distance from top of sludge to bottom of outlet tee or baffle: '7
Scum thickness: 0
Distance from top of scum to top of outlet tee or baffler
Distance from bottom of scum to bottom of outlet tee or baffler
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid.level 1n relation to outlet invert, structural
integrity, evidence of leakage, etc.)
C1/1✓J///o n � /J/1 3 G CP
GREASE TRAP:_
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _FRP —other(explain)
Dimensions:
Scum thic"ness.
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom rni cror^ i^ bottom of outlet tee or barite
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. et(..)
(revised 8/:5/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
y� 1 SYSTEM INFORMATION (continued)
a 1'Property Address: 37FYY\e3 � Cic 7—ca ,
Owner: 'D Rr`�
Date of Inspection: e�j
TIGHT OR HOLDING TANK:_
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _FRP —other(explain)
Dimensions:
Capacity: Qallons
Design flow: Qallons/day
Alarm level:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:_
(locate on site plan)
Depth of liquid level above outlet invert: 1,5r-,7
Comments:
(note iflevel and datribe :r,- eq,.:a' e,.;dp CP et solid C,,r\,n%,er, evidence of leakage into or out of box etc) NO S16di
PUMP CHAMBER:_
(locate on site plan)
Pumps in working order:(yes or no)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 8/15/95) 7
I
i _ 1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 8 IRm`e-S Wn (�` CeZ-' 'At ,
Owner:
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS):—
(locate non-intrusive methods
may be approximated b o )
(locate on site plan, if possible; excavation not required, but y pp Y
if determined o present, explain:
not Bete ed t be ese t e
P P
Type:
leaching pits, number:
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 ponding, condition of vegetation,etc.) S/6/!S o�
Problem
CESSPOOLS: _
(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 groundwate-.
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: Dimensions:
Depth of solids:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(zevised'8/15/95) 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: �8 A me S W(N.,— CrTt2i,,(I C
Owner:
Date of Inspection: J
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
v
� T3
r
(L„
'(,Mcs
DEPTH TO-GROUNDWATER
Depth to groundwater feet
r h
° ' r df
aiy p i r xs i t £ a i� •s �X pry X /� firms yG
p,+m r -Y u+x..+b "�—" �R:.- n...er� rs sv�.r�-•,.aNcx V-�.-.-.�,��r,"_,r<..,-� "'4�^/c���� �"- .�„c <�' 1'�":"'c�4+s��•'t'�•h°-°`�, .
a-.Z v-•,+��yy v �+�+^v -,�,zr+-���''.q"°... .�-�:Yms•-�. ,<�.�,.x � rf`4 S' �t- µ ��ir".'Y' -> a�-.,-v-,+n�
s _ ;. `� r�s x a � �- �•�;� '�` � ti�6��-ct-.L{„t � t t s
tYavi9ia; �f'41`
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Address of property 378 Ames 1-v,;y REMOVED
Owner ' s name Dk. Co,�e�
Date of Inspection AUG 2 5 1995
. ASS. ai, t�Rs
PART A HEALTH
CHECKLIST WM OF BARNSTABLE
Check if the following have been done :
Pumping information was requested of the owner, occupant, and Board of
Health.
Z -, 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 .
3 As built plans have been obtained and examined . Note if they are not
available with N/A.
The facility or dwelling was inspected for signs of sewage back-up.
The site was inspected for signs of breakout .
All system components , excluding the SAS , have been located on the
site`:
. The septic tank manholes were uncovered, opened, and the interior of
the septic tank was inspected for condition of baffles or tees,
material of construction, dimensions, depth of liquid, - depth of
Sludge, depth of scum.
The size and location of the SAS on the site has been determined based
'on existing information or approximated by non-intrusive methods.
5 _ - The facility owner (and occupants , if different from owner) were
provided with information on the proper maintenance of SSDS .
I
r
8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION
FLOW CONDITIONS
If res i)dential.., r �u
'I--I-�J HTJA3H
; 'v �10
number ofedrooms
/ number of current residents
_ garbage grinder, yes or no
`ES laundry connected to system, yes or no
`Ic.S seasonal use, yes or no
If nonresidential , calculated flow:
Water meter readings, if available: ao19'3 U
Oc\ Oar Last date of occupancy
GENERAL INFORMATION
Pumping records and source of information :
✓er C C-� Ov am
eS System pumped as part of inspection, yes or no
if yes, volume pumped
Reason for pumping :
M/J t A 1 c r 1 S (
Type of system
_v'- Septic tank/distribution box/soil 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 known. Source of
information:
.16 >R5- -T ido -S-,1., 5-, 1 q'?j
90 Sewage odors detected when arriving at the site, yes or no
9
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SEPTIC TANK:�o 6A1
(locate on site plan)
Fi
depth below grade : /
material of construction: concrete metal FRP other(explain)
dimensions. a/6
sludge depth
distance from top of sludge to bottom of outlet tee or baffle
" scum thickness
Yo 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, recommendations for repairs, etc. )
DISTRIBUTION BOX:
( locate on site plan)
+Everk depth of liquid level above outlet invert
Comments:
(note if level and distribution is equal , evidence of solids carryover,
evidence of leakage into or out of box, ecpmmendation for repairs, etc. )
A/V 51r17J o�sa/!o/ C/9/�7 DGC'Z
PUMP CHAMBER:
(locate on site plan)
pumps in working order, yes or no
Comments:
, (note condition of pump chamber, condition of pumps and appurtenances,
recommendations for maintenance or repairs, etc. )
10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SOIL ABSORPTION SYSTEM (SAS) : �17
( locate on. site plan, if possible; excavation not required, but may be
approximated by non-intrusive methods)
If not. determined to be present, explain:
Type
leaching pits and number
leaching chambers and number
leaching galleries and number
leaching trenches, number, length
leaching fields, number, dimensions
overflow cesspool , number
, Comments:
(note condition of soil , signs of hydraulic failure, level of ponding,
condition of vegetation, recommendations for ma}ntenance or repairs, etc. )
/l�p SOGn i B
CESSPOOLS ( 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, recommendations for maintenance or repairs, etc. )
PRIVY :
( locate on site plan)
materials of construction
dimensions
depth of solids
Comments:
(note condition of soil , signs of hydraulic failure, level of ponding,
condition of vegetation, recommendations for maintenance or repairs, etc. )
11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100 '
F'.;: -1)00R
38,
�---Armes ?( :T d9.6„
DEPTH TO GROUNDWATER
depth to groundwater
method of determination or approximation:
ys GN'A'." i S„f1„C�
�6, 1 ��
12
SUBSURFACE SEWAGE DISPPOASRAT C SYSTEM INSPECTION FORM
FAILURE CRITERIA
Indicate yes, no, or not determined (Y, N,
or ND) . Describe basis of
determination in all instances . If "not determined" , explain why not)
/ Backup of sewage into facility?
Discharge or ponding of effluent to the surface of the ground or
t v
surface waters?
Static liquid level in the distribution box above outlet invert?
Li uid depth in cesspool <6" below invert or available volume< 1/2 day
q
flow?
� Required pumping 4 times or more in the last year?
A p g
number of times pumped
substanti�o Septic tank is metal? cracked? structurally unsound? imminent?al
infiltration? substantial exfiltr
Is any portion of the SAS , cesspool or privy:
a below the high groundwater elevation?
No within 50 feet of a surface water?
within 100 feet of a surface water supply or tributary to a surface
water supply?
/✓o within a Zone I of a public well?
,No within 50 feet of a bordering vegetated etland or salt marsh
(cesspools and privies only, no
!fo within 50 feet of a private water supply well?
MO 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 analysi
for coliform bacteria, volatile organic compounds, ammonia nitrogen
and nitrate nitrogen.
13
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART D
CERTIFICATION
Name of Inspector
Company Name
Company Address
Certification Statement
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true, accurate and
complete as of the time of inspection. The inspection was performed and
any recommendations regarding upgrade, maintenance and repair are
consistent with my training and experience in the proper function and
manitenance of on-site sewage disposal systems .
Check one:
I have not found any information which indicates that the system fails
to adequately protect public health or the environment as defined in
310 CMR 15. 303 . Any failure criteria not evaluated are as stated in
the FAILURE CRITERIA section of this form.
I have determined that the system fails to protect public health and
the environment as defined in 310 CMR 15 . 303 . The basis for this
determination is provided in the FAILURE CRITERIA section of this
form.
Inspector ' s Signature � au�✓��
Date ✓ aa, J9S5
Original to system owner
Copies to:
Buyer ( if applicable)
Approving authority .
TOWN OF BARNSTABLE r
l • R n
LOCATION AV-\e,5 SEWAGE#T e Z to n
VILLAGE QSJ(DeR✓I 1 ASSESSOR'S MAP & LOT U ,Q g-
INSTALLER'S NAME&PHONE NO.�t'vC e\AOXC 1l i�111— Lion-'S-ra9
SEPTIC.TANK CAPACITY \1 oG c) G N4
LEACHING FACILITY: (type) .(size) cry Sal
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility -29 Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) A1/4 Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facili Feet
Furnished by
38° `
Ln,d
.+�.C..f..
.........
. - !�1�... Fxs....3®.�...
THE COMMONWEALTH OF MASSAC.H[JSETTS
BOAR® OF HEALTH
-----..."".Town..................OF..........Barnstab le..------------..._..._...........1...--------
Appliration for D-Wposal.10orkii Tnnitrnrtion thrmit
Application is hereby made for a Permit to Construct (X ) or Repair ( ) an Individual Sewage Disposal
System at:
Lot $-----------•-Amen.WaY_.....Centerville �__ g v� .........
.... .....
=' --Location-Address
Owner - Address
w = 529 _1C ......................................
......... Q_Q.. --------------
Installer Address
Type of Building Size Lot3,6,3.83...........Sq. feet
UDwelling—No. of Bedrooms----------------3--------------------------Expansion Attic ( ) Garbage Grinder to)
Other—T e of Building No. of persons............................ Showers — Cafeteria
a Other.fixtures ...--•-••......................• .
W Design Flow..............5 -------------------------gallons per person per day. Total daily flow..................3JO.................gallons.
WSeptic Tank—Liquid capacit3liOW..gallons Length------8t.61t Width...41.10y Diameter________________ DepthV.6.......
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No-----------1_....... Diameter.......1JD.!...... Depth below inlet......6............ Total leaching area....26.......sq. ft.
Z Other Distribution box ( X) Dosing tank ( )
Percolation Test Results Performed b3Cape...God•--Survey---Consults ntsDate.......6/W`79-------------
Test Pit No. 1.......2.......minutes per inch Depth of Test Pit-------1,2_------ Depth to ground water_-none.......
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
.............................................-------------------------------------------
------._....---------------•---------•-------------•------------------
0 Description of Soil...0,0p Q,8.. �.11,---D_. �1...Q..�+rood.-l o3tn,-••l._Q-2.D...subsoil..........................
x 2,-Q'4,-5---caarse...sand,---4-.5r!A,.5---led.----coarse__-Sand. -
v
W •-----••------- -------- _ 12 med__fine.._sand.
U Nature of Repairs or Alterations—Answer when applicable______________________________________________________ _ova_..................... .
..........................................................•------•-•-------•---------•--............-•--------•--•-------------...............••............ ........
Agreement: MONAHAN C�
The undersigned agrees to install the aforedescribed Individual Sewage Disposal S to ilm(acP6j)d5nc w'
the provisions of'ME 5 of the State Sanitary Code— The undersigned further agrees n
operation until a Certificate of Compliance has been issued by the board of health. FS8/0iVAI
Signe ................
• -•--------•-......•-••-•--•-••-•-•-•-•--••-•-•-••--••••••.----•• ... •.-- ,iy_
ate
Application Approved By.......... � • `" - D.
---•------•-
A Application Disapproved or the following reasons---------------------•• ------------------------------------------------------------......-•-•-----••--
PP PP f f 9
' -7 �5 ^7 Date
PermitNo......................................................... Issued_.......................................................
Date
V
..........................
No._............. ..... FEz..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Town 0 F Parinstable
. .................. .................... .............................................................................
Appliratiou for Disposal Works Toustrurtion Vrrmit
Application is hereby made for a Permit to Construct (X ) or Repair an Individual Sewage Disposal
System at: #4 r
Lot 38 A m 0 14�..W Ay.3....Pt eryi11e..:i..j4
..................................................... .... . .............. .. ...... ..............................................
Location-Address or t No.
.......cic .1ZS.................................. .........................................
Owner Address
urmltao%�.o.....TAOU................................. .......�&QX)ektxv I&. ...................................................
aInstaller Address
Type of Building Size Lotl,6.6JA ...........Sq. feet
U
Dwelling—No. of Bedrooms................3--------------------------Expansion Attic Garbage Grinder 00)
Other—Type of Building ........................... No. of persons............................ Showers Cafeteria
Other fixtures ........................................................................................
-----------------------------------------------------------
W Design Flow......... . r,t;... .....................gallons per person per day. Total daily fl,6w-----------------J1.3 0.................gallons.
1:4 Septic Tank—Liquid ca�pacity.000..gallons Length......81.61.1 Width...4.1.101 Diameter................ Deptl-142.6!1.....
Disposal Trench—No..................... Width..._._.._._.____.___ Total Length.................... Total leaching area....................sq. f t.
Seepage Pit No---------- ... Diameter.......10.1...... Depth below inlet.....61.......... Total leaching area...267......sq. f t.
Z Other Distribution box Dosing tank
0-4 Percolation Test Results Performed b3Cape__._Cad...au=.ey----Cai2$.U1trSntSDate.......611-1/7.9.............
�4
Test Pit No. I......2------minutesper,inch Depth of Test Pit-------112........ Depth to ground water...TIOTM..........
""Jest Pit No. 2................minutes per inch Depth of Test Pit.___...._.__________ Depth to ground water..______.._____.._.___..
Fij ,0_0` I .
..........................i,*...............................................................................................................................
0 Description Of Soil-- Mi-..0..ktiac&.104m,....1..J0.:n2_..Q Q. Wb.,S.Oil.-,.........................
2 .0!,!t 4- _51 C-0--3-r S----a� M ac 2!0 a X,S-a._a-a)ad...................................
U ............................
-----------------------------------8.5-I2.ril mad--fina...amd,---------------------------------.................................................................
U, Nature of, Repairs or Alterations—Answer whqn.. applicabl------------------ --------------------------------------------------------------------------
...........
............................ ................................................................................................................................ ..............
Agreement: .1 -
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health
Signegi. ................................................................ ................................
Date
By.......... . .......Application Approved' i .. ..................
7............
'; +Za e
Application Disapproved for the following reasons:.................................................................................................................
........................................... .....................................a.......................................................................................................................
Date
PermitNo............................................................ Issued..............................I.........................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HE�LTH
..............OF...1 $3V.T.AMkZ...........7..........
Trrfifiratr of Tompliaurr
THIS IS TO CERTIFY That the Individual Sewage Disposal System.constructed (V�or Repaired
by.........VE..7QJ&.J..U*......I&0.1�.....................................................................................................................................
Installer
4
at......1%, a..............................................
.&T....4%.......ui%wu.......c MICA .................C S
has been installed in accordance with the provisions of TZ2n of The State Sanitary Code as dt `b d i tl sc in the
._.��.e.... ....
application for Disposal Works Construction Permit NOFV--.Al;t-7............. dated....7_!'� --- . ... ....
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY4,....,,
DATE.................................................................................� Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSET/TS
I -
IS RD OF HEALTH
'TOWN.............OF_75,Nklmsx..N. ...............................
....
........................
N FEE
Disposal Works TIMustrudion "Vrrmit
Permission is hereby granted----..Mao-ou.L=......."Um*...............................................................................
to Cortstruct�(%;/). or Repair an Individual Sewage DisDosal Svstem
Nol-0 ...46......M ......Ct ............
at .........................................
Street
as shown on the application for Disposal Works Construction Per N ed.....7--- ..... .............
.......... ... .....................
Board d h
r� of Health
............ I DATE-------------------------- �/.......................... 7
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS J .
............
0
Sh
1
k
3 7 8 A,
-1 A T I HsgrJt-IC SEWAGE PERMIT NO.
38 CAS
VILLAGE
IN T tLLER'S NAME R ADDRESS
anN� 0�-
0 U'i L D E R OR OWNER
(;k- V \ \
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
r
48
0
--
.4 .` SOIL - LOG
'� d - �,P!A>)10Mt a��•..L�AY • PI tl 1!°YA% -_ •. - � R St,
ST
.. . , V. 4��C.1. BOX 1 � i•:�►:.' 100,0 GAI. pp���r-
000 • o r A A o „ a .6d�&C SA!W
IO'MIN. COAL: j:":• PRECAST OR .
,F` 24
SEPTIC I.•.. ,BLOCK • �..k
MIN
TANK 6'I, ••:rb' SEEPAGE.
PIT
20' MIN_ --- ''I • ' • d• c
�..�.►s I
_ .. FOUNDATION . 1 np� .r
i
• WASHED STONE
,. 1.
ELEVATION SKETCH
. PE.#t':0.�R 11TE�%�r��.L'.�.%.,�•�' +�
lE TEST BY '�Nr.- cLN
ma TOWN INSPECTOR: 2•+� 1- A144 �r14 .,
1.
' BACKHOE OPERATOR: r
y TEST MADE ON
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IV
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11 I
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MONAHAN
A
ti
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all
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-.� � .�'r�,a�yc3'•'�'",�t�« , rn:�.��^ ,. p;�s 1 art G r2 t�4 1• � * - _. �. . •
_ � ��:� ��T`r+�wT�D� peat 1.`� �"�-�� ��� �.�� •
.�B o�taoms k //cr Clr t,. pt 't' 1 330 Cat t �' 4k'
1 I0y .PkhowARI.E pAt9X Ft,aw.
v�,E 4 '*r' �S 3 r5
. . Nof 51 t+5 t88 =F X z.3' 4;1?D- s� - y7o (r.A 40.
IJAMES ' GO fro In
' o LAP5LEV'
�s r oQ J) 7'ory v WA-r �2 /4v14f t� 1t 17,1, �
4 ELEVATION. - SCHEDULE
PROPOSED FSITE PLAN
I. tNV. AT FOUNDATION' c 983 •
SEWAGE'. SYSTEM :•OESI N W
2. INV. INTO SEPTIC TANK = 57g--�--�
• t N
3 I NY . OUT OF SEPTIC TANK = 97'67 j
4. INV. INTO DISTRIBUTION BOX- - 77 Ki9 7 E
• SCALE: i=,= LO` .
5. iNV, OUT OF DISTRIBUTION BOX - •Gb C •744-T_, t'
c r c.�D CAPE COD SURVEY. CONSULTANTS ' ^
6. INV. INTO SEEPAGE PIT =
ROUTE 132
4 7. BOTTOM OF PIT _ 91• so HYANNIS ,MASS.
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