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HomeMy WebLinkAbout0145 BRALEY JENKINS ROAD - Health 145 Brailey Jenkins Road,Centerville A= R au Al UPC 12534 No. 2-153LOR ` � HASTINGS, MN -- - - - - Commonwealth of Mossochusetts John Grad . Executive Office of EnvlronmerrtalAffairs D.E.P. Title V Septic Inspector - -Department of P.O. Box 21 19 Environmental Protection -. Teaticket, MAO2536 - (508).564-6813 - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A. - - CERTIFICATION - "q&v �p Property Address: 145BraleyJenkinsCentervlIle Address of Owner: f Date of Inspection Z99 7124/96 (If different) C.; Name of Inspector:John Gracl Dooley " e Company Name, Address and Telephone Number: ttt CERTIFICATION STATEMENT I certify that 1-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: x Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails J U ' Inspector's Signature: vl Date: 7124196 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A. B, C, or D: A] SYSTEM PASSES: X I have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] 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 1 111 519 5) One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500 1 c - SUBSURFACE:SEWAGE DISPOSAL SYSTEM INSPECTION FORM - - PART A - _ — CERTIFICATION (continued) - P rope rty Ad dress: 145 Braley JenklmCenterville - Owner: -" Dooley t0a-te of Inspection:7124196 -Sewage backup or breakout or-high-static water level observed in the distribution box is 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 I _ odstruction-is-removed - distribution box is leveled 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 system has a septic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a surface water supply. _ The system has a septic tank and soil absorption system and is within a Zone 1 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 volatile organic compounds indicates that the well is free from pollution for that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm. 3) OTHER 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 in 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 cesspool. SAS is in hydraulic failure. (revised 11115195) 2 x _ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM i PART A CERTIFICATION (continued) �. Property Address: 145 Braley Jenkins Centervule Owner: Dooley Date of Inspection:7124/96 - t _ - a 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_). Numbers 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 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable; attach copy of well water analysis for coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria: - The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: the system is within 400 feet of a.surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area (IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00.. Please consult the local regional office of the Department for further information. (revised 11115195) 3 - SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST - -" Property Address: 145 Braley Jenkins Centerville Owner: - Dooley —. Date of Inspection:7124196 Check if the following have been done: X Pumping information was requested of the owner,occupant, and Board of Health. X None of the system components have been pumped for at least two weeks and the 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. X As built-plans have been obtained and examined. Note if they are not available with N/A. X The facility or dwelling was inspected for signs of sewage back-up. x The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout. X All system components, excluding the Soil Absorption System,have been located on the site. X 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. X The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. x The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11115195) 4 _ _ e SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION-FORM _ PART - - - - SYSTEM INFORMATION, Property Address: 145 Braiey.Jenkins Centerville - Owner: - -Dooley Date of Inspedtion:7124196 FLOW CONDITIONS - RESIDENTIAL: _ Design flow: 330 gallons Number of bedrooms: 3 Number of current residents: 2 - Garbage grinder(yes or no): No Laundry connected to system(yes or no): Yes Seasonal use(yes or no): Yes _ } Water meter readings,if available: nla Last date of occupancy: Summer use COMMERCIAL/INDUSTRIAL: Type of establishment: Va Design flow:0 gallons/day Grease trap present:(yes or no) No Industrial Waste Holding Tank present: (yes or no) No Non-sanitary waste discharged to the Title 5 system: (yes or no) No Water meter readings, if available: n1a Last date of occupancy. a OTHER: (Describe) Na Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System has not been pumped. System pumped as part of inspection: (yes or no)No If yes,volume pumped: 0 gallons Reason for pumping: n1a TYPE OF SYSTEM X Septic tank/distribution box/soil absorptions 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 information: 1988 Sewage odors detected when arriving at the site: (yes or no) No (revised 11115195) 5 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C. - SYSTEM INFORMATION�contlnued) - - Property Address: 145 Braley Jenkins Centerville _ Owner: Dooley _ Date of inspection:7124196 SEPTIC TANK: X - (locate on site plan) Depth below grade: 2' _. Material of construction:X concreate metal_FRP_other(explain) - - Dimensions: L 8'6'H5'7'W4'10" Sludge depth:u - Distance from top of sludge to bottom-of outlet tee-or baffle: 27' Scum thickness:2' Distance from top of scum to top-of outlet tee or baffle: Distance form bottom of scum to bottom of outlet tee or baffle: 16" Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) Septic tank and all components are structurally sound.Recomend pumping system every two years for maintenance. GREASE TRAP:_ (locate on site plan) Depth below grade: nla Material of construction: _concrete_metal_FRP_other(explain) Dimensions: n1a Scum thickness:n!a Distance from top of scum to top of outlet tee or baffle:nla Distance from bottom of scum to bottom of outlet tee or baffle: nla Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) Na (revised 11115195) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PARTC _. SYSTEM INFORMATION (continued) - - - Property Address: 145 Braley Jenkins Centerville Owner: Dooley - t- Date of Inspection:7124196 �y TIGHT OR HOLDING TANK_: (locate on site plan) Depth below grade: n1a _Material of construction:—concrete—metal FRP -other(explain) Dimensions: n1a Capacity: nla gallons Design flow: n1a gallons/day Alarm level: nla Comments: (condition of inlet tee, condition of alarm and float switches, etc.) n1a DISTRIBUTION BOX: X (locate on site plan) Depth of liquid level above outlet invert: Liquid level with bottom of pipe. Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box etc.) D-box is structurally sound. 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.) nla (revised 11115195) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C. - SYSTEM INFORMATION (continued) Property Address: 145 Braley Jenkins Centerville Owner: Dooley -- ) Date of Inspection:7124/96 _ SOIL ABSORPTION SYSTEM (SAS):x (locate on site plan, if possible; excavation not required, but maybe approximated by non-intrusive methods) If not-determined to be present, explain: - - n1a - Type: leaching pits,-number: 6x4 pit - leaching chambers.,number:nfa leaching galleries, number: nra leaching trenches,number, length: nla leaching fields, number, dimensions:nfa overflow cesspool, number:n/a Comments:(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) The leach pit was empty at the time of the inspection Ills structurally sound CESSPOOLS:_ (locate on site plan) Number and configuration: nra Depth-top of liquid to inlet invert: nra Depth of solids layer: nfa Depth of scum layer: nfa Dimensions of cesspool: nfa Materials of construction: nfa Indication of groundwater: nfa Na 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.) Na PRIVY: (locate on site plan) Materials of construction: nfa Dimensions: nfa Depth of solids: nfa Comments:(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PrivyComments �j. I (revised 11115195) !I' 8 ;i: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - .r'• PART C SYSTEM INFORMATION (continued)- Property Address: 145 Braley Jenkins Centerville Owner: Dooley Date of Inspection:7/24198 -SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references-landmarks or benchmarks locate all wells within 100` I� A Ac. �3� q DEPTH TO GROUNDWATER Depth to groundwater: 12 feet method of determination or approximation: USGS maps and charts. (revised 11115195) 9 No..... ..... Z Fx ... ._. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ............... ..... F......r i .. .... Appliration for Disposal Works Tonstrnr#'ton Prrmit Application is hereby made for a Permit to Construct (ko<or Repair ( } an Individual Sewage Disposal System at: St 13 c,oado}- ddress ) +� or No. .... . '—��1 r �f ... ..�' r! ram- _..._ ...................... .. = ._.... _....-. f ._.... _---•----., .._.. -. ._ ,� Owner 1eV" Vy Address Installer Address Type of Building Size Lot... .Sq. feet f 4 Dwelling—No. of Bedrooms__________________ ______________________Expansion Attic, -�---- Garbage Grindert--t' 1__��!��. No. of ersons___-____��_________________ Showe — Caf p'�-, Other—Type of Building _____ p �.s-(�-'—• ;� Q' Other fixtures --------------•-•---------- •- - w Design Flow_________________________a '' _gallons per person per�dYy. Total daily flow..__._.. .__�_____._.___gal�lons� 1� WSeptic Tank—Liquid capacity/_______gallons Length__ _ __ Width_._/e_ Diameter________________ Depth__ ______... x Disposal Trench—No_ ____________________ IAidth.................... Total Length.................... Total leaching area__._______�.ssq. ft. Seepage Pit No------------#....... Diameter......1.. __._. Depth below inlet____ a__�______ Total leaching.area__�_,�'�_sq. ft. Z Other Distribution box (11-K Dosing tank_ - - '-' Percolation Test Results Performed by.____ ._a?�_g�°_' __ ________..... Date___.l. L_ ',,� � a �' - ,4 Test Pit No. 1............. per inch Depth of Test Pit._._L__�r___. Depth to ground water..___.e����___•__"t (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-------_................ ............................................ - .................. Description of Soil - .. ._..•---•-•-------- -- . tZ Uw •--••••---••---------•------•----•••••••-•••---••._..._._..•---••--• ......................... ....•------•-------_.___..----_...---•----------•---------•------•------••••_.._.._..•--•-----•---•--- Nature of Repairs or Alterations—Answer when applicable................................................................................................ ----------------------------------------------------------------------------------•••--•---.----•---•••-•-•-••-••••-•------••••-•--•••-•••---•---•------•=--•-•---•-...-••-•...._...-••------......•••. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLEE 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 boar of h. 1 e�('w��_ Signed---+�..��/%! --- -•-•-----•--.......---••-_-•-- CY/ ate p� Application Approved BY ---•---••-••--••-•-••••••.... --••• . . -- -•• 1 ` DJ Application Disapproved for the following reasons_____ _______________________________________________________________________________________________________ ............................•---------------•---••-•--------•----•---•--•--•--•---•---••--...--•---••••--'-•----•-------------•-•-••••••••-•-•••-•••••-•----•••--••-••••...----•••••----•••--._.....-••-- Date Permit No......... Date No......�� �...... Z FE$.......................... THE COMMONWEALTH OF MASSACHUSETTS BOARD -�OF HEALTH_ /�4--a 432 --.........-.................................................... Appliratinn for Bispaa al Works Tongtrur#inn 1krutit Application is hereby made for a Permit to Construct Repair ( ) an Ind1v1ftd7SCvage Disposal System at: r lZ '' ... - ..._ ................................7 ........... ...........•-------•-----------=-------... ..�-�. - ....--•----- �: Location-Address or Lot No. ••--•--•••-------........:.. . .•- ...............................................Owner � � Add.ress................................................ W a ......................... ......... - .� .-.:i�.-�.-.I. ......__...._._.--•----•-------..._._..._...---...._._........---..............................__. Installer Address Q Type of Building �J Size Lot.._�'�...............Sq. feet Dwelling—No. of Bedrooms____________________________________________Expansion Attic (`� )'— Garbage Grinder a Other—Type of Building �_._ �'""'_` `. p (r) - Cafeteria(�'-)-' _/. No. of ersons____________________________ Showers" Otherfixtures .----- -----------------------------------------------•-----------------------------------------•---••----- ••_:_.. _� ..... . W Design Flow.......................... gallons per person per day. Total daily flow---___________________-______.._.__.________gallons WSeptic Tank—Liquid capacity l_.__.____gallons Length__ ........ Width__. _r��'. Diameter________________ Depth__ '______._ x Disposal Trench—No_____________________ Width........._,.......... Total Length................. Total leaching area..____________, q. ft. Seepage Pit No..................... Diameter.......t._.�'_.__ Depth below inlet....A!_ .___. Total leaching area....' .�`'_sq. ft. Z Other Distribution box ( L)� Dosing tank-(-77y` t / `-' Percolation Test Results Performed by f _�'x .�'_..��_._' %! ! W ,•••-••-•••-••••-• Date -...---_- Test Pit No. 1................minutes per inch Depth of Test Pit................... Depth to ground water........................ �X4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ODescription of Soil--------. � ---------------•---------...---••--•••••----••-.;•.•.- ............. '�- ---------�- - f� ---- ..................................-- ................................. G W U Nature of Repairs or Alterations—Answer when applicable............................................................................................... -----------------------------------------------------------------------------------------•'•••----•••••••-••-••--•---••--•---•••----••--•-•---••••------------•-••-•••••••-•••••--•••---------••••••. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITTLE 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. r- Signed•-•• .............................................'--•••-•--------•-•--•-•..._....._ ......................... G^' Date Application Approved BY Date Application Disapproved for the following reasons:-_ _______________________________________________________•_________•_•-•-------._..._..._.._____......._._ ...........................................•-•-•---•••-•--••••-•-••••-••-------••------...•--•-----••••-•-••-•-•-•-••••••••••••••••-----•••-•---••-••••••••----••-•----•-•••••••••--••--•--•.......-_•-- Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH T.c� ✓f/r✓ .��'—�.'�'mil/ .ST�7 � ' (5rdifiratr of ffoutpliFanrr THIS IS TO CERTIFY, That the Tnriividual Sewage Dis osal System constructed ( Zror Repaired ( ) by........................ — _'' '- 'Q V \v� G G / -5,4 � GL / Instal —t "'7 / r] .S. /Z rl CC at.-••••-•••._...-••- " --•-••-••••-•.._...-•••--•----••-•-•••----•-•-••••••-•-- ..........---•.... has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE............. $_. Inspector. ................................... .................... 4 C j 17 -a-"CTHE COMMONWEALTH OF MASSACHUSETTS I/ _ BOARD OF HEALTH g..........................................oF._...:............ ............................................................. ,. No......................... FEE.......................! Disposal Por Tnn#rnr#ion rrntit < Permission is hereby granted...........-"' .._. ........... ................................ l to Construct ( )or Repair an Individual Sewage Disposal.System u atNo.-•-•--••••••-••-._.....•••-_.... :•_�t.....................•••-----•••-...... .....••. ---- Street <?6- 7 y! as shown on the application for Disposal Works Construction Permit No................. Dated___..___._..S'.._..j6 r 4 Board of Health DATE_ ,V ' (p -----•------•- .._._..-•--••••---......_..••---•---•--. 1 ' FORM 1255 HOBBS & WARREN, INC., PUBLISHERS TOWN OF BARNSTABLEfy/ff��k ' t LOCATION \p\ '' \may C��a\P er\( ��s SEWAGE # VILLAGE c�. ���\�\R ASSESSOR'S MAP LOT— Qo INSTALLER'S NAME PHONE NO. 1 SEPTIC TANK CAPACITY \ y y�y O QLEACHING FACILITYAtype) (size) 00 © NO. OF BEDROOMS 3 PRIVATE WELL O PUBLIC WATER BUILDER OR OWNER , DATE PERMIT ISSUED: DATE . COMPLIANCE ISSUED: 18' -ao -� 7 VARIANCE GRANTED: Yes No r ;A 9a��S P F�oc�� No.......... -..C�.--.. l Fx .... � r THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ApplirFa#ion for Dispoii ai Works Ton.strur#inn 1hrmit Application is hereby made for a Permit to Construct ('Kr Repair ( ) an Individual Sewage Disposal System at• ri S£d 1+_5 --• ®..r...1. '1.'. F, , .• ... ............................2_.... `�._��. ................. Location-Address or Lo _ • Own - - -•-• dress w .. ev..!rl.... f �--- ............. A aL f_cf�_............ ------ a Installer Address d Type of Building J Size Lot---3-1,,----------------Sq. feet V Dwelling—No. of Bedrooms................. ................Expansion Attic, � Garbage Grinderj� Other—Type T e of Building Gf a yp g ?�-��__.__ No. of persons....................... Showers Cafeteria--(--) P, Other fixtures -------------------------------------- --------------------------------------------------------------------••---------------------.----------------- d - W Design Flow...........................- _�-��..gallons per person ei dad. Total daft y flow____....... . ._ ....--......gallons. 41 WSeptic Tank—Liquid'ca.pacity,h ?gallons Length-----__.-- Width----1._K13.`°Diameter................ Depth5`�--0..�.. x Disposal Trench—No--------------------- Width............ Total Length.................... Total leaching area....................sq. ft. / ' s� Seepage Pit No............ _____.. Diameter...... .... ........ Depth below inlet_._:___________ Total leaching area.... s•_sq. ft. Z Other Distribution box ( Dosing to '-' Percolation Test Results Performed by_______________ _� ;�.�_... _ _._______..._.. Date..... .... ` ,14a Test Pit No. 1...._'f�--{-... minutes per inch Depth of Test Pit... ....... ... Depth to ground water-__ .._... Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water____-_-------__---_____- a ---- ------ O Description of Soil ` ` ✓-` :®. �' �i �•�.-. ...I.. --.._.... .r _"�? � ................................................ .________________________________________ ____________________________________ l�d� W .......................................................................................................................:................................................................................ UNature of Repairs or Alterations—Answer when applicable--------------------------------------------------------------------------------------------- ----- .. Agreement: The undersi a e s t install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'I'LL 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 health. Si e&.. •-•--........-•---•---------•.................. ...........G�.. .-----.Application Approved By.. ..... ......... ..... Date Application Disapproved for the f ollowin reasons:............................................................................................................._ .........-•----------------------•-------------------------....--•------......------------.......-----.....-------------------------------------•-•--------------------------------------------•----•-- Permit No.------..... ' Date---------- Issued--------------------------------•--•------------------- Date No......................... FEs.. ..............._ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH e 6' 3 ` tiN�....OF...... ''.f �2 /\/ i�. L Appliration for Disposal Works Toutitrudion rami# Application is hereby made for a Permit to Construct (v) or Repair ( ) an Individual Sewage Disposal System at: l 0 r- 1 ................_--------` !�r•.-.....c..:t.../....e..,............J. .e...;...�..�..._....�...-�•-•'....i.Z...� Cl e.................................. Location-Address r Lot N [_ e p� //� ��s _-D 4? . L cam.- J= Ci/� �C (� l� Z f�yC,'���� Owner Address Installer C Address �1� - Q Type of Building 3 Size Lot............................Sq. feet Dwelling—No. of Bedrooms.....................................__.__..Expansion Attic Garbage Grinder 44 Other—Type of Building _____.. �'.5...� No. of persons.................................._.___. Showers ( ) — Cafeteria( ) Q' Other fixtures ....I........................... W Design Flow............................................gallons per person peg day. Total daily flow__._......_..:'S.._...._..............._..,gallo s.� WSeptic Tank—Liquid capacityZ.0d gallons Length-__8....1_.. Width....�...�a. Diameter_______--__ Depths x Disposal Trench—No. .................... Width... .............. Total Length............... . Total leaching area........____._---.--sq. ft. Seepage Pit No................. iameter....... Depth below inlet............... Total leaching area..................sq. ft. Z/" Other Distribution box ( Dosing tank:-(� r. Percolation Test Results Performed by__......_..............................,3.._. .y.................. Date............. .....-.... Test Pit No. I..... ...........minutes per inch Depth of Test Pit..............._.... Depth to ground water..................... wTest Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ `------. . - .............................................................................................................f� � Cs ------------ ODescription of Soil ` --- -__-.. --------•------•--•......... .........�-�--- ------✓---------........................... x . j � ' ' ----•----•...................•---------.....-•-•••-••-•----•-------•---•--.....----......•---•---� , "-....... _ . _ " ,.................................................. w -----------------------------------•-----------------------....------------------------------------------------------------------------------------------------------------------------.............--- U Nature of Repairs or Alterations—Answer when applicable................................................................................................ ` . _�......._.. -----------------------------•--•------------------------------------------------------------------------.----------------------•-••------- Agreement The undersigne 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. Sig�d_ ... >�t Application Approved B J �...k --............... ate Application Disapproved for the following reasons:...................................................................... ..............................._.... ---------------------•-------•-----........-------•----------...------......----------.........--•----------•--•--•--•----•---•--------•---••------------------•--••----------••-•••---•----••--••...--' Date PermitNo........................................................ Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... Trrtifiratr of Tomplianrr THIS IS TO C -L Y hat the lndkvidual gew.-iQe Disposal System constructed ( or Repaired ( ) by .........••-• ..... •. Installer P, f+✓� / p at.........------•---------•----------•-•-------------••--..............s/...................................................................................................................... has been installed in accordance with the provisions of TITIE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dated-............................................... THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No.........................o �( ........ ................................•-............••.......-•-• FEE._ -A ............ �t��o� l �rk� o #rion rrmi� Permission is hereby granted..........1V.4.............--.... �Q: --------------------------------------------------------------- to Construct (� L)'or Rep Individual( an 'Sewage �D. is posa�l � stem j� �7 � <<" Y ��_P,�� `1 � atNo..---•-•-•-------••••--•..... .................................•-----•----•. ...---......----•------------- ---------------------------------••--•------ t f• .............;f.�Jf as shown on the application for Disposal Works Construction Permit Street as Dated.........' . ....f .............. 1 � �( -------•------•------- -i'r --.... ��,�1MV` 10 �� g� Board o �Health DATE......---•----------�1- -----------------•�-----............------...._. FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS TO./�N�,jF,$ARNSTABLE LOCATION �r,� `�� ���\e �53-vs&�\,, USEWAGE # 86 - 4 l O VILLAGE - ` ASSESSOR'S MAP & LOT L Z - E,� INSTALLER'S NAME PHONE NO. SEPTIC TANK CAPACITY \ co y � LEACHING FACILITY:(type) (size) 6{jC) QNO. OF BEDROOMS PRIVATE WELL ORLIC WAT BUILDER OR OWNER Le��� - DATE PERMIT ISSUED: DATE . COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No I� � - S� � �� ��� �' '" /r � i ' � � ��`�2 fo�3., 3 6 j �� .. i a \S�3„ \� � � �3 � C`'C o c..� � , ­_'7,,-�77:` 77,`� 7-7-,-.� 7_ 7 I s 0 D A r Et'. C7/V I T, -S'E D :�B Y Q,4 54 X, 4C0"i P*A;C 7� FF7.Z I 40 /cp Q 7 -4 17 'ND COVER � T`O', ELE V. ,TO P , OF UANHOLES 'A BE V I Lt w I r m I N � ,. ,FOUNDATION - 12".. OF ,� FINISH D G R_* D 'E -'kA I N LOP E SHED lo 4- CA ST,I RO, 7, 0 Pvc� S . :1 R C)1 4 p SIT� CH . 40 lo 1 0 vc s IN L A Y E R _EVEC A S�TO N�E�, 14 PITCH V 0 F T.�� Colo — �' 1- 'fNVERT � DIS INVER I N V E R T �8,0 X --1'1/2 7 N V ERT� .1c 4 D't A. E D.,"S TO* TANK I N VE RT WASH N E ,, J!Okr. W�C3 0. ALL,, ARO m,w r-1 10 E LE V. 8 OT�7�0 M G'R NO E S A � GAR I NV C R T,� Ui M I N. R COOT r -P I T p IN. E L c H E . ("eo 7.POLi7 .4 a P R 0 P I,L E',� 0 F, GROUND WATE R LE A kN I TA R Y D 1 S,,,P S'Y ST E M S�A L N OTI.TO E �DE S I G' N `�� ,DAT A OOMS BE D R 'D I S POSAL 'CONSTR UCTI 0 N OF ,SAN fTA R Y DESI , C) G A-L`- D*A:Y G N T, L 0 W, ? SYSTE M . S H.A LL CONFORM TOWAS.S., 'R tEAC�H ATE s N, IINC, W TA L CODE _T'I T L',E' Y_ (REV ISED 7- 1 77) E N V.( R 0 N M E N., PROPOSED L'E A C A P A C I T Y, , IS 7' AND THE TOWN -0 F a 10-> 5 7- a /Z HEALTH , R E,G U LAT I ON S. PTIC TANK DISTR I BTION BOX AND LEACHING o-SE -E D, C 0 N C RET - P I T T O ,S E O'F.,,R E I N F OIR C 443 , PS11 GAL A:Y MIN. CONCRETE' STRENGTHl- 3000, E"N'd rH E E Lf,, _5 T MM S T_ 2 o0ops H 10 �DE S I G�-N LO�A.DING:-�'. D 'OVr LOC'AtE E.R -SYSTE M. * ;:DRIVE WAYS ' N O7.TO ,,B 0 'r o A "I U N L tS s�,H DE'S I N L N G ,A S U-3 E'D. A L L T I N G S T 0 T A 1� D P 1,P ir,S WN T 'A 0 B 0 �ST RO N CO R �'SC H E.D 0 P.V.,C. 'SW, OF� S HS. -'G : P - 'C �N STRUCT ON, 7 �E H OWUN' S ED,, �5 7 �4 wl V �4 �L 6cAT I ON EL:G E N D­:� rz p P, PPO V FOR .D H,E-A L T H 'OF T E 1�,­B OAR'V S C A LIE: RE N t A 'PE R : E UILDING SETBACX-,�RE,GULATI N EX I S r I N G C 0 NTO U,R MG- INSP E'C'T OR �O'R �B U I,L D UN G 16 -P R 0 PO S E D 0 NTO U R '� DATE A G'E'M M 15 S I O'N E R'. C,O E X I S T I N G_�t'P OT E LE VATI-O N, 1 7.�6 N.',FRONT, S ET 6 AC,K- OF ERV I C E PRO POSE D' WATER : s K KA I N ' _-5 t ,D E", SETS CRAIG RT- 1-17 -LO C-AT 10 N ES T. H 0 L E N.,-,R E A R S 8 T/B A C K L 74 I N c V AL, AL P R 0 F E S, S I ON A' L N D' S­U R �E Y,0 R S E N G I N EE,R S , j-4 PRT 15-8 -M Al S7 4 RT,E ­ 6 N I'Si, M A'S:S 02,6 : i z x L S O .. L 0G DATE_ /0 z Jpz� WITNESSED �--+ a ; H BY. , �. o T / 2 71�. .S tJ L L I �;,r' �=r r✓ — �a X T�+-�=rL s' r✓vim' ' 4� Al J J 7 •, M �`L7/UJ1r� G G 2, 0 ELEV. T0P OF MANHOLES AND COVER TO BE BUILT WITHIN FOUNDATION ,-�-' 12" OF FINISHED GRADE . } `•. r � ' - FINISHED -' -- RAIN. 2� SLOPE r, f RADtr 4- CAST I R O 4., P V '• :. . .•... . :..• C SC 4 0 ' . IST , PVC SGH. 40 ' d�',.i. ' PITCH I 4" FT. ' 2 LEYELs. . t0'r :rt MIN. 2" LAY ER J �8 p'' PITCH /o "v; ' r ''�`, I�$ 1/2 PEASTONE `n / Z_ 9 1 N VE RT �`�� 7 iNvERT GALLON t ERTI DIST. INVE T o_O H d • SEPTIC TANK i INVERT 8 O X ` --�e. 7�.'r' c+C� r< C]9 A - 3.S d 3/4r. 1 1/2"D I A . :yp u uta" WASHED STONE l INVERT nap waEd3°' ALL AROUND . rJ p46 ' ®p IO GARAGE Q -i . AAiN• GRINDER ELEV. ® OTTOM .t D'+;d'; 2 0� RA 1 N. - 3' Es/ D I AL+t°- OF P IT = -3,2S" _ ELEV. _ 49,p PROFILE OF GROUND WATER TABLE 2r- LOW SANITARY DISPOSAL SYSTEM . NOT TO SCALE ESIGN DATA13 ptr?_ aposE _2z CONSTRUCTION OF SANITARY DISPOSAL BEDROOMS r` sr I r�aJ•�1LY DESIGN „F LOW 330 SYSTEM SHALL CONFORM TO MASS. GAL ./DAY LEACH RATE ENVIRONMENTAL CODE TITLE V (REVISED 7- f - 77) �` ' MIN. INCH 37, 4. 7' AND THE TOWN PROPOSED LEACii CAPACITY : HEALTH REGULATIONS. I, ��•N m r,. �Iv SEPTIC TANK, DISTRIBUTION BOX AND LEACHING 2z,3 tq; c�Asrx zlo�r - PITTO BE OF REINFORCED CONCRETE : E r� M1N. CONCRETE STRENGTH 3000 PSI GAL/DAY r. TEE L STRENGTH MIN , S 20,0OnPS1 c j H ( 0 DESIGN LOADING S � _ I4_W I DRIVEWAYS NOTTO BE LOCATED OVER SYSTEM r ✓ w UNLESS H- 20 DESIGN LOADING IS USED. � . I ar ALL P.I PES AND ,PITY I NGS TO BE WATERTIGHT AND TO BE OF CAST IRON OR SCHED 40 P.V. C. SITE PLAN SHOWING PROPOSED CONSTRUCTION r LEGEND L 0 C`A T t 0 N: RA/ 5 7,e:3 j3 LEr, J765�',�V Ac) .V ; ® R ` s - APPROVED 19 CAGE. � � � ' ® ATE : _ / a IS- BOARD OF� HEALTH BUILDING SETBACK REGULATIONS PER EXISTING CONTOUR - -.-1 6- E F E 'R E N C E: : BUILDING INSPECTOR- OR BUiLDt,NG POSED CONTOUR 16 COMMISSIONER . PRO DATE AGENT MIN. FRONT SETBACK 2d ' EXI STING SPOT<ELEVA71ON 17. 6 MIN. SIDE SETBACK ` PROPOSED WATER SERVICE- MIN. REAR - SETBACK TEST HOLE LOCATION �' � FS JJ c • R . SHE RT ( N C . .. ,. PROFESSIONAL ,LAN �>. JI D SURVEYORS � ENGINEERS ��........_..._.-�' 1586 MA1,N STREET CRT E. 6A ' ), EAST DENNIS, MASS. 02641