The URL can be used to link to this page

Home My WebLink About0156 BRALEY JENKINS ROAD - Health 156 BRALEY JENKINS RD Centerville ' A = 172 "209 SMEAD KEEPING YOU ORGANIZED No. 12534 2-153LOR SUSTAINABLE FORESTRY MIN.RECYCLED INITIATIVE CONTENT 10 0 Certified Fiber Sourcing POST-CONSUMER www.dpro9rem.orp W412G0 MADE W USA GET ORGANIZED AT SMEAD.COM I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments - l10 G tG .w 4M Property Address �► MM Owner Owner's Name information is Q� r-v! required for every -. page. City/Town State Zip Code Date of Irfspectibn Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information 514P 13143 filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not use the return Name of Inspector // /�key. 'E �/V Y t O G (�1 Company Name 0 eo /C� C7 Company Address (/wsACWP7 _-_ City/Townorcr-e) nio State l _�� Zip Code Telephone umber 7 License Number B. Certification 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 15.000).The system: Passes ❑ Conditionally Passes ❑ Fails ❑ N ed Further Evaluation by the Local Approving Authority IVI O Inspector Signature Date The system inspector shall 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 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. ****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. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments / M Property Address OorZ Owner Owner's Name information is eN j4WI/, l{ required for every page. City[Town State Zip Code Date of nsp ction B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System P es: 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. Check the box for"yes", "no"or"not determined" (Y, N, ND)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. ❑ Y ❑ N ❑ ND (Explain below): t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name information is required for every CQN Joevi/!/ { o,.�6 -70� 8 �� page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 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(1)(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 t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 • r Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments enj,,7yl Property Address Owner Owners Name Rspebnt information is �required for every page. City/Town State Zip Code Date B. Certification (cont.) 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 fecal coliform bacteria indicates absent 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: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ Re",- Backup of sewage into facility or system component due to 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 ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El than depth in cesspool is less than 6" below invert or available volume is less than'/z day flow t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments /s er a 1-e 907 Pvl�✓/Hl fled Property Address OU/e Owner Owner's Name D�fo l information is ��w-ter✓I 1//� A required for every �! page. City/Town State Zip Code Date of In ection B. Certification (cont.) Yes No ❑ Required pumping more than 4 times in the last year NOT due to clogged or /obstructed pipe(s). Number of times pumped: ❑ �i—�'/ Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ Any portion of 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. ❑ ny 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. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent 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 and chain of custody must be attached to this form.] ❑ M The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ElThe 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 flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. 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 II 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. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments /e Tke9411 Ae, Property Address onre, Owner Owner's Name AA/{ information is o0a�3� required for every y�—►G O 2/f/ page. City/Town State Zip Code Date of Inspeetion C. Checklist Check if the following have been done. You must indicate "yes"or"no"as to each of the following: Yes �00 ping information was provided by the owner, occupant, or Board of Health ❑ Were any of the system components pumped out in the previous two weeks? ❑ as the system received normal flows in the previous two week period? ❑ Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? Were all system components, excluding the SAS, located on site? ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ 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: Existing information. For example, a plan at the Board of Health. ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): ----- Number of bedrooms (actual): — DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Z 3 0 t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form R Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address oor� Owner Owner's Name IAA information is �� ! i Qa 6 3.z Tin required for everypage. City/TownState Zip Code Date sp ction D. System Information Description: MOO 6� j l e s��e�►�,.- rah D Number of current residents: Does residence have a garbage grinder? ❑ Yes No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes No information in this report.) Laundry system inspected? El Yes [ No Seasonal use? ❑ Yes VNo Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes No Gti✓.(eN Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑, No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,Q ra le .ems lrr n Property Address 6 oor4- Owner owner's Name�QN ` // l L information is � 0� 10 3„ :1;7 required for every page. City/Town State Zip Code Date of I pec n D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes No If yes,volume pumped: gallons How was quantity pumped determined? ---- - Reason for pumping: Type of Sys 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)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins.doc•rev.6/16 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments (/ ^ Property Address Owner Owner's Name information is // r required for every `'e N. "i 4 DC2`� F� V v page. City/Town State Zip Code Date of Insp ction D. System Information (cont.) Approximate age of all components, date installed (if kn wn)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): Depth below grade: F feet Material of constructi�40 ❑ cast iron PVC ❑ other(explain): - — --- -------------- Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below feet Mated of construction: concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: �5 x g Sludge depth: Cz t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments QN Property Address 41 Owner Owner's Name. information i e � �`` Ae, required for every page. City/Town State Zip Code Date of Itfspeclon D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): W /✓1 I-� (Ove, re C o(Mo.Fn- c/-e G'. l 4w �✓ Gv1 g 4,,�S I✓1 aver Coy G 4494 . x4 Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle — Date of lastpumping: Date t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M � 5�0 _ ro• �� _�PN kf ded Property Address 000ez- Owner Owner's Name information is �� /"/ /L Q�6 3.� required for every ��— _. _ /T — page. Cityrrown State Zip Code Date f 161spectforn D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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: ga�Ions per day __ Alarm present: ❑ Yes ❑ No Alarm level: ----- Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No rf Sewage Disposal System•Page 11 of 17 t5ins.doc-rev.6/16 Title 5 Official Inspection Forth:Subsurface g p Y 9 X, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address oo O Owner Owner's Name information is 64004rvt Aerequired for every page. City/Town State Zip Code Date of spe on D. System Information (cont.) Distribution Box(if present must be opened) (locate on site pla Depth of liquid level above outlet invert 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.): n� Lam/ Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): located, explain wh If SAS not ocat :p y t5ins.doc-rev.6116 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address A100 r�i Owner Owner's Name A information isN /�/4 ou 9required for every �f-cr(�� L �T co 32 $ p page. Cityrrown State Zip Code Date of spe Ion D. System Information (cont.) was. , Type: ye( �� leaching pits number: ✓✓✓ ❑ leaching chambers number: ❑ 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.): Po e7 d 1 P"5 1,;0 440 Aa t$1 ,Zt Nt /�o vti X10 4C-7r-�-C C 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 ❑ No t5ins.doc•rev.6/16 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M er,'- le 617 Tesr 4e-ivif W Property Address oore- Owner Owner's Name C-a / �� T z information is W V-4., //{ y��✓� ,g required for every page. City/Town State Zip Code Date of spec n D. System Information (cont.) 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.): t5ins.doc•rev.6/16 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 14 of 17 L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address 1170 � c Owner Owner's Name �� f information is �� /j required for every ��t� �Vf �� l V page. City/Town State Zip Code Date of(nspe0fion D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two pAFm�Yhen reference landmarks or benchmarks. Locate all wells within 100 feet. Locate �hand-sketcre p is water supply enters the building. Check one of the boxes below: h in the area below ❑ drawing attached separately C 14 1 Gyl1o✓t SQp�tL T��v C3 - 39 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M l G ra/e 9,7 Property Address Owner Owners Name l- information is oa 611 required for every page. City/Town State Zip Code Date of In ection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells ! �- �� Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ rved site (abutting property/observation hole within 150 feet of SAS) Checked with to Board of Health -explain: ��,s - - 7'FS� fqo/.es ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You mu scribe how you established the high ground water elevation: /�Oc' Iful 40oO/ a ;e�� a.o �` Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6116 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 16 of 17 a , � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System For -Not for Voluntary Assessments Property Address Ohre Q� Owner Owner's Name information is ��a required for every page. City/Town State Zip Code Date of Inspec on E. Report Completeness Checklist Inspection Summary: A, B, C, D, or E checked Inspection Summary D (System Failure Criteria Applicable to All Systems)completed stem Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 rt No .. Fss............................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 4-8 � .7 (S� pplirFatinn for BiipniFal Works Cnnnitrnr#inn amit Application is We y ma a fora Permit to Construct ( 01`60'r Kepair ( ) an Individual Sewage Disposal System at: 7 Z "Loll ... l- - ...�.`7...lat�ion�S�° �:-` - �_'_'_��3' -a ..f � �..r'-�..�..Q'.`_�°F/. - ddress r Lot No. _..f...---••-- ----- _ ----------- s .. - --- --•-.�-.. ...i..............._.. W Owner K�V �Ox �� Address s C •..._... _... ............... .......... . --.--- l ............. [- ........--- Installer Address Type of Building Size Lot__f� .� c'._Sq. feet U Dwelling—No. of Bedrooms,. .._/__________________Expansion Attic—(�' Garbage Grinder per, Other—Type of Building ...) �'�.•'��!.No. of persons.........�--------------- Showers (� Cafeteria, a' Other fixtures ------------------------------------------------------ W Design Flow...........................°�..�� .gallons per person per day. Total daily flow..............�._�.. ............gallons. WSeptic Tank—Liquid capacityt-�-t- gallons Length.... .--.61.. Width_.L .- Diameter................ Depth.=7--•_ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sa. ft. 3 Seepage Pit No...........I....... Diameter....... Ze... Depth below inlet...... Total leaching area... ft. Z Other Distribution box ( Vr Dosing tank,( . r '-' Percolation Test Results Performed by._..._�' ?'-' �'....'=........•...._.... Date.... a � ,,�- a Test Pit No. 1._ '. :minutes per inch Depth of Test Pit...... .Z..._. Depth to ground water----- Z_...f.. fi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 9 ••-•--•. ------../--••------••--•-••--•••-•-•••.....c............ - --------------------- O Description of Soil................. .........e: '•-• .......... P ._.......... _._.. - ............................................................................ U Nature..of Repairs or Alterations—Answer when applicable............................................................................................... ----------------------•----•--------•-----•---•----•-------------------------------••-•-------••-•--------•• -••-•-......_..•-••...•--•- Agreement The undersign - ag� to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iI'LUj 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issue by the boar f lth. Signed .....-• . . ................................... to Application Approved BY _ ..... Date Application Disapproved for the following reasons:...............•....•.••..................___....__.._..___._........_._.__....................._____......__.� •-------••----•--•---•--•--......-•--•---...----.....-.-.. -••-•--•--•••--•------------•-•- ••--------- Date — Permit No...............�sue( .-----��o....... Issued..................................................... Date No. Fps: ............ THE COMMONWEALTH OF MASSACHUSETTS �'-� BOARD OF HEALTH T' 4-d ...................................... OF.......................................................................................... Applira#ion for Disposal Works Cnnnstrnr#iun rnmit Application is hereby made for a Permit to Construct ( q-or Repair ( ) an Individual Sewage Disposal System at: ... E' -� c� Location-Address / or Lot No., 'l 2.6 -.,ems i I d� 1 y r '�--� } ,-✓7 - - ...................�:........... ........._.... -•----••-----------•--...---•------.......--•-----------••-•------...___.._..-•--•............... V%V-1 Address sw®eYi.."!� Fes{ IC k'o-� a .............••........... ..------------....--------•-- ..................... :..... - .. Installer �� Address Type of Building Size Lot........ ................Sq. feet a Dwelling—No. of Bedrooms__.c ___ __________________ExpansionCAttic(�) G�ge Grinder ' a Other—Type of Building _._l_______________�.___-No, of persons............. Showers ( ) — Cafeteria ( ) Otherfixtures -:--........................................................................................................ .......... _........................ Design Flow........................... ``� gallons per person er, y. Total dai`y fiow_.._.___.___._'�'�_. __________.gallons ,. WSeptic Tank—Liquid capacity ____...._ gallons Length________________ `��.Width_ _____ ._ Diameter................ Depth._ _......__-- x Disposal Trench—No� .. ____________________ Width Total Length.................__:Total leaching area_______...___._..:&q. ft. Seepage Pit No_____________________ Diameter....... __��__ Depth below inlet...... S.. Total leaching area.._. _�sq. ft. Z Other Distribution box ( Dosing tankr(_� '-' Percolation Test Results Performed by............................•� t Date . ----•----_ . Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water____------_'_____-----_- 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water......._................ xDescription of Soil.........................................................-�----...---••----------------- V ---------------•-----------------------•...._._...---------- . W -----------------------------------------------------------------------------------------------------------------------------------------------------------•------•------...---•-------•-•...•--....... U Nature of Repairs or Alterat s—Answer when applicable............................................................................................... -----------------------=----------- --- •-------------------------•--•-•--•--------------__------------------------•-------------------------------------------------•---------_----- Agreement: 6 The undersigne agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITIE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Sined, .-- _-------•------•--••----•-•------------------------ --------- 1APPlication Approved BY �_--•-- . ------.. .............. �---------------.......--•__--•-- Date Application Disapproved for the following reasons_______________________•________•____-__•___________-__-•_-----•---------•-•-----.---....._...________.....____ -•------------------------------------------•---•---•--------•-•----.......------•---------•----....---._._........------•-----------------------...----------------•------------------------------••--•- Permit No............... ........ �o---•--• Issued...........................................Date------ Date THE COMMONWEALTH OF MASSACHUSETTS _ BOARD OF HEALTH 0 ...........�. w� OF.... f -�f�i� '' - ......................................................... Trdif iratr of Tnnaplianrr THIS IS TO CER� TT®!That the Individual dew, e Disposal System cQgstru-ted ( �or Repaired ( ) by ...--••------•------------•---,. �-----....-•-----------------•---- •----.-...-....�v.� T"t__. ��: - h�stauer at.. -----•---•-------•-------------------•-•------------•-......-••----- has been installed in accordance with the provisions =of TITLE<=_A=;Tl �e Sanitary Coder as des I,i d in the application for Disposal Works Construction Permit No_________________________________________ dated__--______-----_f ._. _.._____________.. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE............. .L:-�f ............................. Inspector_ .............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD _OF HEALTH .................. No......................... FEE........................ ..Dis�ros al arks T� inn .er�ti# Permission is hereby granted.... i T v�� C U -=:":"..'"__......�.,z....--------.-------------------------------------------------------------------- --------- to Construct ( '<or jRep r ( )- Indivi ual Sewage Disposal System- j� /� atNo........................................................................_y......••--•-----••----._.._..-------•-------............ Street as shown on the application for Disposal Works Construction Permit_No.....` .... '_i____,__ D ted__________ -----------------------------------------------------------•----•--_---- OBoard of Health DATE..............---•------I-d._ _�....------ FORM 1255 HOBBS & WARREN. INC., PUBLISHERS --' TOWN OF BARNSTABLE LOCATION(o'k"%,A aa, cca\ .I'SsVILLAGE ASSESSOR'S MAP & LOT c� INSTALLER'S NAME & PHONE NO. try SEPTIC TANK CAPACITY c-? n LEACHING FACILITY:(type) (size) ®NO. OF BEDROOMS PRIVATE WELL OR BLIC WATE BUILDER OR OWNER DATE PERMIT ISSUED: DATE . COMPLIANCE ISSUED: 7 G - - VARIANCE GRANTED: Yes No 6� 7 ' -L 3/1 I S .6� ell SO I L LOG ¢ F3 47 D A T E W I T N E 5 S E D B •v : c. 41 31 f J44 \lK i T, rl�,IO t 1 etL. ?a i��' co .1 ELEV. TOP OF UANHOL£ S AND COVER TO sE BUILT WITHIN 10 T / •t .' i o' F OUN D AT 1 O N OF FIN ! 5 k# E D G R .4. D E I 27- SLOPE 1 Q I 0 — / '� rd �, i . STT"mt arrr: , N t S H E D 6 R A D E 4"G AST I R O IS T -. 0R .. . . .•.,. :..• 4" PVC 5C 40 t ' PVC SCH. 40 . ..; WITCH If4 FT. 2� LEVEL'. . dfA N. 2" LAYER 4 r 692 ry \ k T+jC H /O ✓ .i • ..e i 0 _ ,/2.rPEA5TONE trNVERT ? i ! 0 tN � RT DIST : frVERT' o=O �ti. �,e •A4 e I t 2.,DIA� V ED 5TONE a �iv RT i+.eC'+ W dAROUND �' CaA EI 59 sL t: y..ti,- i•.r _._;L' u a_ �:<+ i %' MIN. 6R ! ND'✓MR ' •..... _ __�I ELEV. BOTTOM � ?�' .�sr v �— — 4 I ELEV. s 9: PROFIL E OF r 6ROU�N0 WATER TABLE S A N IT" ARY DISPOSAL SYSTEM NOT TO SCALE DESIGN DATA 4 ::)AAr, � _.r . r� ec# , . ; BEDROOMS • CONSTR UCTION OF SANITARY DISPOSAL SAL. DESIGN F L 0 W GAL .�DA�r `� SYSTEM SHALL CONFORM TO MASS . LEACH RATE 'iL MiNJINCH ENVIRONMENTAL CODE TITLE Y (REVISED `?`- i - 77� PROPOSED LEACH CAPACITY : AND THE TOWN COF :. J , ?", % HEALTH REGULATIONS. -' • SEPTIC: TANK, DISTRIBUTION BOX AND LEACHING PITTO BE OF REINFORCED CONCRETE : � '`� `�. _. GAL/DAY MIN , CONCRETE STRENGTH 3000 PSI MIN . STEEL STRENGT-H 2000aP31 H 10 DESIGN LOADING • DRIVEWAYS N INTO BE LOCATED OVER SYSTEM UNLESS H - 20 DESIGN LOADING IS USED. • ALL PI PES AND FITT I NGS TO BE WATERTIGHT AND TO BE OF CAST IRON OR SCHED 4.0 F.V C. SITE PLAN SHOWING PROPOSED CONSTRUCTION SH, ,-- OF ' - SHS LEGEND L 0 C A T I O N FOR _ .. s � L. V,:F p. APPROVED ( 9 SCALE: DATE : _._% � BOARD OF HEALTH --__ _- BUILDING SETBACK REGULATIONS PER EXISTING CONTOUR - - --15--•--•- REFERENCES - 7" fZ �- ,/. cif`,° X'✓ 8 BUILDING INSPECTOR OR BUIL. DI,NG PLA Btr 30 ,/ ,� 7 _- COMMISSIONER PROPOSED CONTOUR __ I6' � DATE AGENT r\/ IN FRONT SETBACK 24 EXISTING SPOT ELEVATION 17. 6 > � MIN. SIDE SETBACK PROPOSED WATER SERVICE yy f�h�` �3Fr�ar9c: a1r, TEST HOLE LOCATION � '�� H yG s� MIN. REAR SETBACK ��- r J L C . R . SHORT, INC . SFrlST PROFESSIONAL LAND SURVEYORS L ENGINEERS Fs�IDNAI 1586 MAIN STREET (RTE, 6A'\ EAST DENNIS, MASS , 02641 -i J N. E.