HomeMy WebLinkAbout0119 BLUE WATER DRIVE - Health 119 Blue Water Drive
Centerville P
A - 253 036
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HASTINGS. MN
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
+ d DEPARTMENT OF ENVIRONMENTAL POTECTYON ,
TOWN G` B, 'ILit
HEALTH Ori',
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
I g CERTIFICATION
q
Property Address: 19 Blue Water Drive
Centerville,MA 2.5 3
Owner's Name:David Burlingame MAP
Owner's Address: 19 Bluewater Drive PARCEL �
Centerville,MA 02632 LOT
'
Date of inspection.,January 8,2004
Name of Inspector. John P.Slavinsky
Company Name: Cape&Islands Engineering
Mailing Address: 800 Falmouth Road,Suite 301C
Mashpee,MA 02649
Telephone Number: 508-477-7272
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
_XT Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
i Fails /
Inspector's Signature: + �Lu Date: January 8,2004
i
The system inspector sh submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 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
DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
Notes and Comments
Pump tank
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Page 2 of I 1
OFFICIAL. INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE IDISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 19 Blue Water Drive,Centerville,MA
Owner:David Burlingame
Date of Inspection:January 8,2004
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
X� I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described In the"Conditional Pass"section need to be replaced or
repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please
explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 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
ND explain:
Page 3 of 11
OFFICIAL.INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORK[
PART A
CERTIFICATION(continued)
Property Address:19 Blue Water Drive,Centerville,MA
Owner: David Burlingame
Date of Inspection: January 8,2004
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 public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(l)(b)that the
system is not functioning in a manner which will protect public health,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 any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well**.Method used to determine distance
**This system passes if the well water analysis,performed at a DEP certified laboratory, 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,provided that no other
failure criteria are triggered.A copy of the analysis must be attached to this form.
3. Other:
Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 19 Blue Water Drive,Centerville,MA
Owner:David Burlingame
Date of Inspection:January 8,2004
D. System Failure Criteria applicable to all systems:
You must indicate`yes"or`no"to each of the following for ail inspections:
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or pondmg of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
X Liquid depth in cesspool is less than 6"below invert or available volume is less than'/z day flow
X Required pumping more than 4 times in the last year NN T due to clogged or obstructed pipe(s).Number
of times pumped
X Any portion of the SAS,cesspool or privy is below high ground water elevation.
X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
X Any portion of a cesspool or privy is within a Zone 1 of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
X 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.IThis system passes if the well water analysis,
performed at a DEP certified laboratory,for coWorm 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,provided that no other failure criteria
are triggered.A copy ofthe analysis must be attached to this lbrm.]
NO (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described
in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to
determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design now of 10,000 gpd to 15,000
gpd•
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
— — 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 H of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system has failed The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The system owner should contact the appropriate regional office of the Department.
Page 5 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 19 Blue Water Drive,Centerville,MA
Owner:David Burlingame
Date of Inspection: January 8,2004
Check if the following have been done.You must indicate"yes"or"no"as to each of the following
Yes No
X_ — Pumping information was provided by the owner,occupant,or Board of Health
X_ Were any of the system components pumped out in the previous two weeks
X _ Has the system received normal flows in the previous two week period
_X_ Have large volumes of water been introduced to the system recently or as part of this inspection
_X_ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
_X _ Was the facility or dwelling inspected for signs of sewage back up
_X _ Was the site inspected for signs of break out
X_ _ Were all system components,excluding the SAS,located on site
_X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the
condition of the bales or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of
scum
_X _ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
X Existing information.For example,a plan at the Board of Health.
X— Determined in the field(if any of the failure criteria related to Part C is at issue approximation of
distance is unacceptable)[310 CNM 15.302(3)(b)]
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE IDISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 19 Blue Water Drive,Centerville,MA
Owner: David Burlingame
Date of Inspection:January 8,2004
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Number of current residents:4
Does residence have a garbage grinder(yes or no):No
Is laundry on a separate sewage system(yes or no):No [if yes separate inspection required]
Laundry system inspected(yes or no):No
Seasonal use: (yes or no):No
Water meter readings,if available(last 2 years usage(gpd)):
Sump pump(yes or no):No
Last date of occupancy:current
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sg8,etc.):
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/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the inspection(yes or no):NO
If yes,volume pumped:^gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
_X_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)
Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight tank _Attach a copy of the DEP approval
_Other(describe):
Approximate age of all components,date installed(if known)and source of information:
System installed in 1993
Page 7 of I I
Were sewage odors detected when arriving at the site(yes or no):No
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 19 Blue Water Drive,Centerville,MA
Owner:David Burlingame
Date of Inspection:January 8,2004
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction:—cast iron 40 PVC_other(explain):
Distance from private water supply well or suction lime:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK:_X_(locate on site plan)
Depth below grade:_2'
Material of construction: X_,concrete metal fiberglass__polyethylene
_other(explain)
If tank is metal list age:.__.. Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions: 10,6"x 5'8"x5'T'deep
Sludge depth 4'
Distance from top of sludge to bottom of outlet tee or baffle:_29"
Scum thickness: 2"
Distance from top of scum to top of outlet tee or baffle:_54"
Distance from bottom of scum to bottom of outlet tee or baffle: 12"
How were dimensions determined: field measured
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
Recommend pumping. Septic tank and T inlet and outlet in good condition.
GREASE TRAP:_(locate on site plan)
Depth below grade:__..
Material of construction:_concrete_metal fiberglass_polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or bale:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 19 Blue Water Drive,Centerville,MA
Owner: David Burlingame
Date of Inspection:
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: gailms/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: X_(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:_0"T
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of
leakage into or out of box,etc.):
D-box in good condition.
PUMP CHAMBER: (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
Page 9 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 19 Blue Water Drive
Owner:David Burlingame
Date of Inspection: January 8,2004
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:
X leaching chambers,number:T5-
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology-
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil condition of vegetation,
etc.):
No signs of hydraulic failure
CESSPOOLS: (cesspool must be pumped as part of inspection)(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(yes or no):
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.):
Page 10 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 19 Blue Water Drive,Centerville,MA
Owner:David Burlingame
Date of Inspeetion: January 8,2004
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.
GARAGE
0
EXISTING
DWELLING
36 1 .5'
48.5' 24.5' 1
r-----i O I
I
1 sas
Page 11 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 19 Blue Water Drive,Centerville,MA
Owner: David Burlingame
Date of Inspection: January 8,2004
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 12 feet
Please indicate(check)all methods used to determine the high ground water elevation:
_X_Obtained frarn system design plans on record-if checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Test holes done on March 28, 1989
y ..
_.yFicz
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
......... Wl.................OF........fir, ...............................................
Appliratiou for Ditipoott1 Works Toostrurtiou liPrmit
Application is hereby made for a Permit to Construct K) or Repair ( ) an Individual Sewage Disposal
System at:
..Gdr �3 -- Qfcac Lv�.1sr 37.
.......---•----
t!...---•------•--------------
Location-Address or Lot No.
11n l. .. �arays` .i? .. .Ce��rr��z.d_c.........................
A .Owner -----------------------------••----------•__Address
Installer Address
Type of Building Size ....Sq. feet
V Dwelling—No. of Bedrooms----- r __........................Expansion Attic ( ) Garbage Grinder ( )
pa, Other—Type of Building -------------_.............. No. of persons............................ Showers ( ) — Cafeteria ( )
P4 Other fixtures -----------------------------
d
W Design Flow..................................s ._gallons per person per day. Total daily flow.......................... .*�..Q.._..__gallons.
WSeptic Tank—Liquid capacity_i_5.M._gallons Length.1.0.'-6`�._ Width.15'6`'_. Diameter__-_- ___. Depth ;.............
x Disposal Trench—No..................... Width....k3:_........... Total Length___' :_ ... Total leaching area_._`�31 ....sq. ft.
3 Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box (x ) Dosing tank ( )
Percolation Test Results Performed by `i?Yy. ._. ........ Date__ _.,A----r.Etxh_/..`�r�r
Test Pit No. I___:7 ?_..minutes per inch Depth of Test Pit----- ..... Depth to ground water________ ......
Li. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to round water..
P P---- p g -.
RS ----------••-•------- -------- ----•-•• -----------......._._...._.._... -•••••-••-•_..
0 Description of Soil.... �.�-,---.I��a_ _. a.b .eel t..Z�-. _.._ 1i���''2._ Sae ---------------
:3 °...S..Y t- _ �Wltx�tuxr�.__ `rc�t�_.s .p .b Jc-�_ l_� -� �-� tv.z------------------ - Avs g
E --------•----------------•------------------------•---------.•.•.----------------•----------------------------------------------------------------•-••• ...... .Qh.... en
U Nature of Repairs or Alterations—Answer when applicable................................................................... ° 2
16
Agreement: :... u�
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in ac ord-- 0�
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has be�p issu by the board of health.
Signed ���>'�`,� I!S`�--8 ?Z------ - -%...:..... .. ............................................ .Dare ......
Application Approved By ....... . ---- `--------------------------------------------------------------------- .....7.....
N5-
Application Disapproved for the following reasons: . ......... ..... ................. ... - - --- ..... -..-------------....--....----...-.....-..--------------
-------------------------------------------------------------------------------------------------------------------------------- --- --- ........................................
Dare
Permit No. .,3......�-3--�.......................... Issued --...----------6f...-:��-;J-...�.��.-.-......
No------------------------ Fxx...................._.....
_
THE COMMONWEALTH OF MASSACHUSETTS
BOARD /O11F HEALTH
..........7.ws?................0F.........Gc q.r,a,. --.6Ik.---------......------.........---.............
Appliratilan for Disposal Works Tonstrurtinn Prrmit
Application is hereby made for a Permit to Construct (?ej or Repair ( ) an Individual Sewage Disposal
System at:
r
.......................... ..r . .................
.�? ....
Location-Address or Lot No.
...=...13.%2JAnju ruz-.......------------------------------•-•----•------------- 1 ._Cn ..
anars..X .3 4 u.i..J'c....-----•-----•-- ........
Owner Address
W
Installer Address
Type of Building Size Lot.... l'.Z�Q7-..Sq. feet
V Dwelling—No. of Bedrooms.._.� ..�r... ......................Expansion Attic ( ) Garbage Grinder ( )..�
aOther—Type
of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
d Other fixtures -----------------•-•----••------------------.......---------------
.....
W Design Flow....................................' _gallons per person per day. Total daily flow...........................Z.3.C2...dons.
R; Septic Tank—Liquid capacity..l5oagallons Length.-10-!:n6�.' Width..?�.�_ Diameter____7r7r=... Depth................
Disposal Trench—No..................... Width......M---------- Total Length----3Lti-T.. Total leaching area..... :5. ....sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( X) Dosing tank ( )
aPercolation Test Results Performed by.....4eamy... ....... Date...o2$
Test Pit No. I.....*,vo..minutes per inch Depth of Test P?it......12__...... Depth to ground water......
(z, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
o .................
Description of Soil a-Z. ...10 .�..Saabsai 1.j Z- /}n �u 4 . --•-•-• ..._ .. -
'� sire,•_. . _.-..!�..Imt_clt�e c_b the s' -- -1_-/2.___-". ---..... _
,.Sa . .
W STEPHEN_--
VNature of Repairs or Alterations—Answer when applicable...................................................... At i Yid
---•---------------------------•----------------------------------------------------.....-•--•-•--------••------------------.......-----------••--•----------•• ;
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System s i 7/1
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees the
system in operation until a Certificate of Compliance has been issued by the board of health.
Signed ..... . ....... . .................................................................................. .......................................
Dace
ApplicationApproved By ................................................................... ...... ...................................................................... ...................................
Date
Application Disapproved for the following reasons: ...... .............................................................................................................................
.................................................................................... .......--------...........---......................------------................------..................I...---- ---------..............................
Date
PermitNo. .............................................................. Issued ...................................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.............................................. OF ----------------------...-- --- ..............................................................
(gertiftcttte of Clompltttnce
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by---------------- ------.-----------------..............------.........----------.....................................................
Installer
at .................... ...............................................................................................................................................................................................................:.............
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. ................................................ dated ................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE..........................7 7-...'----72...................... ......... Inspector ....... .. ..........•--................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...........................................0 F.....................................................................................
No......................... FEE........................
Disposal Works Tnntrurtiun jlrrmit
Permission is hereby granted........................................................................................................................................
-
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System
atNo.................••••••-•----•--•----••---........-----•---••••-•-•---•••-•-----••••••........---•----------------------•-•...-----•--•---•--------•--...•••-••----•----••-•--••-••-••-........
Street g 1
as shown on the application for Disposal Works Construction Permit No..../_3_-�c_3.YDated..........................................
r -------------------------------------
Board of Health
.DATE.............. =............................................
Form 1255 HarW HOBBS&WARREN TM Publishers
✓e C �� x''�`WY6WOVARNSTABLE
LOCATION 4 a ► J3 4i ww. l7 ��-o-. Dn— SEWAGE #
VILLAGE r -h ASSESSOR'S MAP Q LOT
I
INSTALLER'S NAME & PHONE NO. o, — a - ? 6'7_7 Z
.A
SEPTIC TANK CAPACITY If"d�-o
LEACHING FACILITY:(type) (size) J J
NO. OF BEDROOMS PRIVATE WELLOR PUBLIC WATER
BUILDER OR OWNER ,
DATE PERMIT ISSUED: J
DATE COMPLIANCE ISSUED: 7 ®7 3 71
'NARIANCE.GRANTED: Yes No
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washed stone N 2" peastone Polyethylene Leaching Chamber
H-20
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6" 4' 2.3' 4' --� 2.3' 4' 2.3' 4' 2.3 4' 2.3'� 4' "
6
35.5'
36.5' effective leach area
PROFILE `°
no scale a;
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PLAN
3/4" — 1-1/2" no scale
washed stone
E Note: Effective width is 6" wider on all sides of the actual bottom area.
(V p
2" peastone
4" sue+ 40 1 Y /2�t3 INITIAL ISSUE /}[�
PVC - ° NO. DATE DESCRIPTION BY
° Polyethylene Leaching Chamber °,01
H-20 °°' _ LEACHING FACILITY DETAIL
Inv.elev. i //\\V//��u//\�u// \I Bottom of
1.75'---J ;OL.system elev. o i 3
BOTTOM OF TEST HOLE 'I � ". ?
OR USGS PROBABLE HIGH WATER LEVEL �SCALE: None JOB NO, f686
contact
SECTION A-AF LEVY, ELDREDGE & WAGNER ASSOCIATES INC.
no scale
ENGINEERS LANDSCAPE ARCHITECTS PLANNERS LAND SURVEYORS
889 WEST MAIN STREET
CENTERVILLE MA 02632
,
BREAKOUT CALCULATION: PERCOLATION SOIL TEST
CONCRETE RISER AS REQUIRED DATE OF SOIL"TEST
'MIN.MIN. SEE NOTES 2 do 3 WITNESSED BY w
PRECAST , n1r�(3
4' SCH. 40 PVC PIPE PERCOLATION RATE `Z MIN./INCH
MIN. PITCH 1/8' PER FT. -6 ct°f
eACKF�iL WITH TEST 'PIT „1 TEST PfT.2i< "
T.O. FOUNDATION CLEAN SAND
8' MIN. ELEV.
.�7 ELEV�' 3• , '„
—d.00 _:b.00
q y [ -1 �y
Irv?f}R* �� /���Oc?a�ilc /L�C w —1r179��r �+. 7�l
49 T.07'' g3 56Q X 330 ate, 373 c{ t G' .+ f PE'� 5
PITCH
1/4- PER FT. ri
q,p
2' LAYER OF
FLOW UNE 1/8, _ 1/2•
WASHED STONE — p
460
lea vJk AT,3JS'( rj
Wirth EJe=1..`,
< WATER LEVEL ADJUSTMENT: TP 2 t,, t,�,-� .� DESIGN CALCULATIONS :
46, I LEVEL zFS
4'-0' q 9, 4 Y ► NUMBER,OF BEDROOMS . ,3
LIQUID / 3/4 — t 1/2 TEST DATE �2 +b WATER LEVEL GARBAGE DISPOSAL UNIT L
LEVEL _ �� WASHED STONE, TOTAL ESTIMATED FLOW
DISTRIBU
TION ON 'I ,5 INDEX WELL 1 {-LLQ GAL./BR./DAY X _ BR.) 3J 0 GAL /DAY
WW WATER LEVEL RANGE ZONE "C, REQUIRED SEPTIC TANK CAPACITY �55' GAL
BOX '� W ACTUAL SIZE:OF SEPTIC TANK DGAL
DEPTH TO WATER LEVEL FOR INDEX WELL
FOR THIS MONTH 2 tv I LEACHING AREA REQUIREMENTS
WATER LEVEL ADJUSTMENT 7, BOTTOM AREA O-7T GAL./S.F.
$40 GALLON SEPTIC TANK " I LEACHING CAPACITY (BOTTOM + SIDEWALL) GAL
" DEPTH TO HIGH WATER �_
RESERVE LEACHING CAPACITY 33-0-GAL
SEWAGE DISPOSAL SYSTEM PROFILE �ffc G`r,.x tFG.c►►s.i Ar«a :3 4.
NOT TO SCALE BOTTOM OF TEST HOLE �or-- vV>a Tc iz,
NOTES:
LEACHING PT
1. ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO D.E.Q.E.
TITLE 5 AND THE _TOWN OF RULES AND ..
REGULATIONS FOR THE SUBSURFACE DISPOSAL OF SEWAGE.
2. ALL COVERS TO SANITARY UNITS SHALL BE BROUGHT TO tr
WITHIN 12"'OF FINISHED GRADE.
�* \ 3. ANY MASONRY UNITS USED TO BRING COVERS TO GRADE ,
_SHALL BE MORTARED IN PLACE. "
�-- 4. ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE CAPABLE
OF WITHSTANDING N-10 LOADING UNLESS THEY ARE UNDER OR
WITHIN 10 ET. OF DRIVES OR PARKING'AREAS. H-20 LOADING
2 ` �� SHALL BE USED `UNDER 'OR 'WITHIN 10 `FT. OF DRIVES OR
P� f � t PARKING.
C \ " 5. HORIZONTAL AND VERTICAL. CONTROL, SEE LEVY, ELDREDGE'
& WAGNER FIELD NOTEBOOK # Z.:S3 ,
( o : t,0CA1ri6K) rL)gGGeta E5Y
v
4
LEGEND:'
EXISTING SPOT .ELEVATION OOXO
EXISTING CONTOUR_..--
11,00
,.
FINAL SPOT ELEVATION
A11
' r-rJ� �.. �`�� � ' �' �c►t s ,, "FINAL CONTOUR .
? \ �
. SOIL TEST :LOC
ATIONuark 5)n2II cun�ta � rL W Wbxfta o r +cn TOWN WATER _
�. .:
SEPTIC TANK
,. C�
,.A11: ra�Ir fczrEcrsh ( rt atn 'tom C O
DISTRIBUTION BOX
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PRIMARY LEACHING PIT ('
r, RESERVE LEACHING PIT t A(•�
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_ BY :
NO. DATE DESCRIPTION
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OFa.HEALTH ;_ APPROVED. BOARD v
:
. C ATES INC.
VY ELDREDGE & AGNER AS SO>. . _ LE
JLD :lLAYE1N IS � INIDATE AGENT
YY'Y MVI,.YIv
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>, P STREET MA 02632 LOCATION >MA S�':b�ATN RVILi.E ,
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