HomeMy WebLinkAbout0118 CAP'N LIJAH'S ROAD - Health 118"CAP'N LIJAH'S ROAD, CENTERVILLE
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No.,. 006 r Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
Rpprication for �Digo5al *pgtem Cou5truction Vermtt
Application for a Permit to Construct( ) Repair(K Upgrade( ) Abandon( ) ❑ Complete System Individual Components
Location Address or Lot No. `A? C/ ��f Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. / Designer's Name,Address and Tel.No.
Imo, S/G a-oea
Type of Building:
Dwelling No.of Bedrooms � _ Lot Size sq.ft. Garbage Grinder
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.r quired) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank f 1 BO - Type of S.A.S. " � � e'UA.00 X.2
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the nvi onmental and not to place the system in operation until a Certificate of
Compliance has been issued by this Board 9fYea
Signed Date
Application.Approved by _ �: Date _
Application Disapproved by: Date
for the following reasons
Permit No. ;�006 —//�p Date Issued 0
006 do
� No. ' ��.� Fee r
THE COMMONWEALTH OF MA►S 'HUSETTS Entered in computer:
"PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
application. for Dig o5ar * gtem Cow5truction permit
Application for a Permit to Construct O Repair.( Upgrade O Abandon'(7) ,0 Complete System Individual Components
Location Address or Lot No. ' �y C ,�f Owner's Name,Address,and Tel.No.
Assessor's Map/parcel �� -( , C ' 13,i!2 I;F-Q¢f e/Ajo ` G a
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
�ti��J /2��� (SQL 4; i a Pow
Type of Building:
Dwelling No.of Bedrooms ,vim Lot Size sq._ft. Garbage Grinder ( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.r quired) gpd Design flow provided gpd
Plan Date Z Ql Number of sheets Revision Date
Title
Size of Septic Tank rJ41 rG ldo0 lug Type of S.A.S. �. fn-/w/ 3��` �U �U *':2
Descriptio-of Soil '
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system'in
accordance with the provisions of Title 5 of the nvi onmental '42 and not to place the system in operation until a Certificate of
Compliance has been issued by this Board o, e t �_
Signed Date
Application Approved by -
Application Disapproved by: r Date
for the following reasonsS
Permit No. e)006 --/r 4 Date Issued — . ]3�0�
5 — g
THE COMMONWEALTH OF MASSACHUSETTS p`
BARNSTABLE, MASSACHUSETTS R
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site wa/ge Disposal System Constructed ( ) Repaired ( Upgraded ( )
Abandoned( )by 0.d l e✓L
at 0 edle, LjqA 40 has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. 2{)66- dated
Installer cod( w Designer
#bedrooms 31 Approved design flows gpd
The issuance of this permits all no b construed as a guarantee that the system will f�'o�`n as designed.
Date C7-6�� Inspector
-----------------------------------
No. 2 00 b -/` � Fee /w
THE COMMONWEALTH'OF MASSACHUSETTS
PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS
ligpogal 6pgtem Corr truction Permit
Permission is hereby granted to Construct ( ) repair ( Upgrade ( ) Abandon ( )
System located at ( 4 ` �j�S Ci✓�'�'�c�! ((�.
and as described in the above Application foryDisposal System Construction Permit.The applicant recognizes his/her duty
to comply with Title 5 and the following local provisions or special conditions.
Provided: Construction must be completed within three years of the date of thief.
Date 3 CO . Approved by ✓fin/.
'I
Town of Barnstable
"'E'` Regulatory Services
. ........:.
Thomas F.Geiler,Director
+ �AR1YSThBEE, +
l Public health Division
arFpA Thomas McKean,Director
200 fain Street,4Hyanhis,MA 02601
r
Office:.508-862-4644 Fax: 508-790-6304
Installer &Designer Certification Form
Date: D 3 2--W/O(e
• v ` • J Designer: )) Installer: _
Address: . �b �l Address:
- �PpjYJY\j)C 4 0253�
On was issued a permit to install a
(date) (installer)
septic system at WI-) �� �b�S I D- based on a design drawn by
(address)
01 f f tv) tW K-/• dated
(designer) IJ
I-certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of he
distribution box and/or septic tank.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system)but in accordance with State&Loc lations. Plan.-ievision or
certified as-built by designer to follow.
OF Mgss9cy
` g DA R N�
Y �. b
( s ll is Signature) i o. 1140 = J�
o !L�
G►sTV
SgAIITAPk"
(Designer's Signature) (Affix Designer's Stamp Here)
PLEASE RETURN TO B TABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE.BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
Q:Health/Septic/Designer Certification Form
- i
Notice: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only
PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM
hereby certify that the engineered plan signed by me
dated O 2"27-04 ,concerning the property located at
i8 (A-P 'Al L!JA-a( J )2VA-0 meets all ofthe
following criteria:
• Two soil evaluations excavated for detailed examination(no hand augering)and two
percolation tests shall be conducted.
• This failed system is connected to a residential dwelling only. There are no commercial or
business uses associated with the dwelling.
• The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes
per inch.
• There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
• The bottom of the proposed leaching facility will be located no less than five feet above the
maximum adjusted groundwater table elevation. [Adjust the groundwater table using the
Frimptor method when applicable]
Please complete the following:
0
A) Top of Ground Surface Elevation(using GIS information) (03 NO GW
B) G.W.Elevation :!� t- - +adjustment for high G.W. _ /� t
26
DIFFERENCE BETWEEN A and B N/q
SIGNED:I DATE:
NOTICE
Based upon the above information,a repair permit will be issued for 3 bedrooms
maximum. No additional bedrooms are authorized in the future without engineered septic system
plans.
n�Senticlnenxxemn.rinc I
• O
TOWN OF BARNSTAB E
I-OCA ION G r /4� SEWAGE#^^ 06(Q
V�LAGE C.Qv���Je d—e ASSESSO 'S MAP&PARCEL 174
INSTALLERS NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) (size) t7 Q —�
NO.OF BEDROOMS
OWNER tjo
PERMIT DATE: _60_ C _ COMPLIANCE DATE:
Separation Distance Between the: ;
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility ro Feet
Private Water Supply Well and Leaching Facility(If any wells exist
on site or within 200 feet of leaching facility) d Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of lea ng facility) , ,' zU d Feet
FURNISHED BY ,�,/1 �/�,,,,P�� gs
�G "�gwGC
aq•s � ,p-� a�
gG-s
3
\p'pTHF Tp� Barnstable
Town of ]Barnstable
A}-Amerira City .
IJi\i 1�t�t, Regulatory Services Department t r
RAR!'TAut.E.�J i! �.
''moo\"i6�q:�s�\�'' Public Health Division ,tit t17
�m
�FD MAt� 200 Win reet, Hyannis MA 02601
Office: 508-862-4644
FAX: 508-790-6304 Thomas A.McKean,CHO
e
A L ION FOR RENTAL REGISTRATION
Date: -,2
Fee:$90.0.0 Per Unit Plus$25 for each
v addd.Unit on the same parcel
Property Location: a
r UCm
UNIT# If Applicable, BUILDING # `-
r7,
Assessor's Map and Parcel: f 1�/767 'v
Total Number of Rental Units You Own At This Property (including this unit)
Owners Name: N a SfA-rvbeA W r-
m
Telephone Numbers (Daytime) `7 -7 s ro/o
(Home Phone) (Cellular)
Owner's Address: 5q ckl n n e:l {o „�f- �� /�/- t � Y/Z A 0-*L 6 o i
Mailing Address: (if different than above)
Owner's'Representative's Name (if Applicable):
Address:
Telephone Number:
Occupant's Name: 5
Daytime Phone Number: 6-0 Sr- 3.) - 3 Rc, 3 Cellular
Number of Bedrooms: 3 Check One: Is this a single family dwelling unit? [v],
an apartment building? [ ] or an accessory apartment? [ ]
Do You Have Zoning/Building Division Approval for an accessory apartment?
Will there be any children under the age of six who will be occupying the rental unit?
• (circle one) es No
Was the dwelling constructed prior to 1979? Yes No
I certify that the information provided above is true:
01, Applicant's Signature
COMMONWEALTH OF MASSACHliSETTS
EXECITTIVE OFFICE OF ENVTRON`MEN-TAL,AFFAIRS
a DEPARTMENT OF ENVIRONMENTAL PROTECTION
l
L--
0to l /oZ /� � a e 4
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORIMI
PART A
Q CERTIFICATION
Property Address: //O CGr ✓J L —�ffS" �GJ
e� ervi'/ I
Owner's Name: 7~�3 -
Owner's Address: /.Z-
ol-
Date of Inspection: _ / -�(,'_p Z
Name of Inspector: (please print) >
Company Name:
Mailing Address: o C /off. 1?- -^�
ZL q w7
TeIepho,ne Number: " - C/CLC G
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 15340 of Title 5(310 C M 15.000). The system:
Passes
Con 'tionally Passes
zeds Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: /—a.
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 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-
****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.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLL1`I'CRY ASSESSME `I'S
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: q #S
Owner: W0/r—
Date of Inspection: / —a(,— 0,6
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
A�— ,have not found any information which indicates that any of the failure criteria described in 310 C_M R
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:
Titlo G Tnenwntinn �nrm�n sionnn 2
Page 3 of i l
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESS TENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: h Z'
Owner: (n/0/F
Date of Inspection:
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 15303(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
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 ffoin 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:
Title G incr�cntinn Fnrm (.lIG/7M(1 3
Page 4 of l l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: CG -k? L/3- -F Qr—j
1f>1'4C 3,2,
Owner:
Date of Inspection: / ^e2 6— OL
D. System Failure Criteria applicable to all systems:
You must indicate "yes"or"no"to each of the following for all inspections:
Yes o
B cicup 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
togged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
sspool
id depth in cesspool is less than 6"below invert or available volume is less than 1/z day flow
_✓Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
times pumped
y 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
}eater supply.
�y portion of a cesspool or privy is within a Zone 1 of a public well.
_ � �'portion of a cesspool or privy is within 50 feet of a private water supply well.
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 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.l
(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 310 CTMR 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.
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)
Xyes
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 si-mficant 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 Ca
15.304.The system owner should contact the appropriate regional office of the Department.
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLLI ARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
Owner: W%_
Date of Inspection: / —oZ to— 0,6
Check if the following have been done. You must indicate"yes"or"no"as to each of the follow-ing:
Yes No
&___1 Pumping information was provided by the owner,occupant,or Board of Health
Were any of the system components pumped out in the previous two weeks?
"--Has 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 NIA)
Was the facility or dwelling inspected for signs of sewage back up?
Was the site inspected for signs of break out?
v 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:
Yes no
Existing information.For example,a plan at the Board of Health.
V — Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [310 CMI R 15.302(3)(b)]
T tlo S (ncnca�tinn P^— 4/i tionnn 5
Page 6 of.11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: l L ITG, 14s
e✓y �YJ% ff pa-�J�
Owner:
Date of Inspection: �
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual): ci DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): �p �G G
Number of current residents: C�
Does residence have a garbage grinder(yes or no): A0
Is laundry on a separate sewage system(yes or no): [if yes separate inspection required]
Laundry system inspected(yes or no):
Seasonal use: (yes or no): fs
Water meter readings, if a ilable(last 2 years usage(apd)):
Sump pump(yes or no):
Last date of occupancy:---/�7
C OMMERCIALANDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sqf,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):
G NERAL INFORMATION
Pumping Records �/
Source of information: /V PG�f
Was system pumped as part of 9CZinspection(yes or no):,Lt/O
If yes, volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
TYP�✓OF SYSTEM
_✓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 contact(to be
obtained from system owner)
_Tight tank _Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date in,�t ed�if known)and ice of information:
Were sewage odors detected when arriving at the site(yes or no):/`/V
411;Ilnon 6
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
/ SYSTEM INFORMATION(continued)
Property Address: // �4 dJ / '7-� s Q�
Owner: O(�=
Date of Inspection:
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: iron —40 PVC_other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK:—(1— ovate on site plan)
Z/
Depth below grade: 13
Material of construction:_&-�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) � X Dimensions:
Sludge depth: /.2
Distance from top of sludge to bottom of outlet tee or baffle: 1-1�
Scum thickness: G I �L
Distance from top of scum to top of outlet tee or baffle: 17( 91
Distance from bottom of scum to bottom of outlet tee or baffle.
How were dimensions determined: Pole ��S c�2 riICL
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels
as®rated to outlet invert, evidence of leakage,etc. : /
///u r
GREASE TR.AP:�cate 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 baffle:
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.):
TiYlo G incr�ortinn Cnrm r./3 7
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: CG !�—ors
eA
Owner: (,</D( f
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: gallons/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: (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: Ao,"'✓IZ q
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of
leakage o or out of bo etc.): I
0 SO/i, r /j/O .moo- �s
PUMP CHAMBER:locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Continents (note condition of pump chamber,condition ofpumps and appurtenances,etc.):
Page 9 of i l
OFFICIAL INSPECTION FORM—NOT FOR VOLLTNT_ARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORYIATION(continued)
Property Address: //C�?Owner:
Date of Inspection: ( —oZ 6 —0/6
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type eaching pits, number:
leaching chambers,number: ��e �G S
leaching galleries, number:
leaching trenches,number, length:
leaching fields,number, dimensions: C t�f 0 L;1 s !p
overflow cesspool, number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure,level ofponding,damp soil,condition of vegetation,
etc.)-f � /� �/ SLci l ri$d/ Cc f/ile /i?I/'C✓'7L--
v) 'C�LAI 1 G �o►�' (4✓fie,
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 ofponding,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.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: /e
Owner: W O/
Date of Inspection:��
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.
04
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Page 11 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESS N1 S
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: h /TG tfs
Owner: �/OHC
Date of Inspection: IRA- 6
SITE EXAM w
Slope / ,V
Surface water
P
Check cellar JaA (
Shallow wells a lao J� I E
Estimated depth to ground water feet a,i a.
Ple:�bta'inetdrfrom
dcaeck) all methods VloonZet-
e-the 'gh ground water elevation:
system design ord-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 des be w you established the high gpuild water evation: //
/ O N
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TOWN OF BARN$TAA�BLE
LOCA'f1ON &Z Ca0 /7 QJ, SEWAGE #
VILLAGE rA IPA, -- ASSESSOR'S MAP & LOT2 9 7
H�1°i S NAME&PHONE NO. Aek-
SEPTIC TANK CAPACITY LEACHING FACILITY: (type) ., ��r (size)
NO.OF BEDROOMS /A "
BbtffiHER E) OWNER
PERMITDATE: A tr/COMPLIANCE DATE:
r
Separation Distance Between the
Maximum Adjusted Groundwa-err Table to the Bottom of Leaching Facility
Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
COMMONWEALTH OF MASSACHUSETTS
j EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET. BOSTON. MA 02108 617-292-5500
WILLIAM F.WELD TRUDY COXE
Governor Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner
' l 0_ PART A
I 1 /. CERTIFICATION
Property Address: 1 1 8 Capt Lij ahs Rd, Centervilledress of Owner.Laurie B McCormick
r 1 9401 Turtle Ridge Ln
Date of Inspection: /�"/3— ! (If different) Northridge, CA 91 326
Name of Inspector: Wm E Robinson Sr
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: Wm E Robinson Septic Service
Mailing Address: PO Box 1089 , Centervi 1 1 P , MA 02632 /uA�
Telephone Numbers,' 508 7 7 5—8 7 7 6
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 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:
!/ Passes
_ Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: L,I Date:"
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this
inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent 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:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
COMMENTS:
B] YSTEM 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.
Indi to 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, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or
the septic tank, whether or not metal, is 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 04/25/97) Page 1 of 10
DEP on the World Wide Web: http://www.magnet.state.ma.us/dep
ej Printed on Recycled Paper
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 1 1 8 Capt Lij ahs Rd, Centerville
Owner: McCormick
Date of Inspection: -7
B] YSTEM CONDITIONALLY PASSES (continued)
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the
Board of Health). Describe observations:
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
":�• *,C] F THER'.EVALU'AhON 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 PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or
tributary to a surface water supply.
The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that
the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method used to determine distance (approximation not valid).
OTHER
(revised 04/25/97) Page 2 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 118 Capt Lijahs Rd, Centerville
Owner: MCCOrmick
Date of Inspection: 01-13-1� 1
D] STEM FAILS:
You m st indicate ei;,,er "Yes" or "No" as to each of the following:
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
he failure.
Yes o
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped _.
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of,a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_ Any portion of'a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E] LA GE SYSTEM FAILS:
You ust indicate either "Yes" or "No" as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
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:
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)
The o ner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requi ements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 04/25/97) Page 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 1 1 8 Capt Lij ahs Rd, Centerville
Owner: McCormick
Date of Inspection: �`„ 7
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
y Pumping information was provided by the owner, occupant, or Board of Health.
_ None of the system components have been pumped for at least two weeks and the system has been receiving normal
flow rates during that period. Large volumes of water have not been introduced into the system recently or
as part of this inspection.
_ As built plans have been obtained and examined. Note if they are not available with N/A.
_ The facility or dwelling was inspected for signs of sewage back-up.
r✓ _ The system does not receive non-sanitary or industrial waste flow.
The site was inspected for signs of breakout.
All system components, excluding the Soil Absorption System, have been located on the site.
The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of
baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
_ The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal System.
_ Existing information. Ex. Plan at B.O.H.
_ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) [15.302(3)(b)]
(revised 04/25/97) Page 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 1 1 8 Capt Lij.ahs Rd, Centerville
Owner: McCormick
Date of Inspection: 3 _q
B LDING SEWER:
(Loc a on site plan)
Dept below grade:
Mate ial of construction: _cast iron _40 PVC_other (explain)
Di ce from private water supply well or suction line ,
Diam ter
Com ents: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK: (/
(locate on site plan)
Depth below grader
Material of construction: concrete _metal _Fiberglass _Polyethylene —other(explain)
If tank is metal, list -Is age confirmed by Certificate of Compliance _(Yes/No)
.p-1 .� i
Dimensions: `C G `-
Sludge depth: '/-6
Distance from top of sludge to bottom of outlet tee or baffler
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: /09
How dimensions were determined: i w
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outle invert, stru�u al .�
integrity, evidence of leakage, etc.) /0 0
T' a2 e
GREAS TRAP:
(locate site plan)
Depth b ow grade:
Material f construction: _concrete _metal _Fiberglass _Polyethylene —other(explain)
Dimen ions:
Scu hickness:
Distanc from top of scum to top of outlet tee or baffle:
Distance rom bottom of scum to bottom of outlet tee or baffle:
Date of I t pumping:
Commen
(recomm ndation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integri , evidence of leakage, etc.)
(revised 04/25/97) Page 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 1 1 8 Capt Lij ahs Rd, Centerville
Owner: McCormick
Date of Inspection: �,.`3_o
FLOW CONDITIONS
RESIDENTIAL:
Design flow:3 30 g.p.d./bedroom for S.A.S.
Number of bedrooms: 3
Number of current residents:.
Garbage grinder (yes or no):Ago„
Laundry connected to system (yes or no�t.�
Seasonal use (yes or no): /t— 1995 — 66 , 000g
Water meter readings, if available (last two (2) year usage (gpd):
Sump Pump (yes or no): /L C 1996 - 41 , 0 0 0 g
Last date of occupancy:I/'/3— 1
COA MERCIAUINDUSTRIAL:
Type o establishment:
Design low: gallons/day
Grease rap present: (yes or no)_
Inclust4 I Waste Holding Tank present: (yes or no)_
Non-sa itary waste discharged to the Title 5 system: (yes or no)_
Water eter readings, if available:
Last date of occupancy:
OT ER: (Describe)
Last of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
a '
System umped as part of inspection: (yes or no) G,
If yes, volume pumped: Rallons
Reason for pumping:
TYPE OF STEM
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)
I/A Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information: oZ/
Sewage odors detected when arriving at the site: (yes or no) All
(revised 04/25/97) Page 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 1 1 H Capt Lijahs Rd, Centerville
Owner: McCormick
Date of Inspection: 37„5-7
TI G
TOR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection)
(local on site plan)
Depth below grade:
Materi I of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain)
Dim nsions:
Cap city: gallons
De ign flow: gallons/day
Alar level: Alarm in working order _ Yes; _ No
Date of previous pumping:
Com ents:
(con ition of inlet tee, condition of alarm and float switches, etc.)
LIZ—
DISTRIBUTION BOX:_V
(locate on site plan)
Depth of liquid level above outlet invert: C/
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
P)Iarmiin
HAMBER:_
(ln site plan)
Pn working order: (Yes or No)
A working order (Yes or No)
Cts:
(nndition of pump chamber, condition of pumps and appurtenances, etc.)
ov—
(revised 04/25/97) Page 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 118 Capt Lijahs Rd, Centerville
Owner: MCCOrnli CSC
Date of Inspection: W^/ 3—C7'' 1
SOIL ABSORPTION SYSTEM (SAS):
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type:
leaching pits, number:
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, c ition of vegetation, etc.) 1 b
Ln .� o
o
a
CESS OLS: _
(locate n site plan)
Number and configuration:
Depth-t of liquid to inlet invert:
Depth o solids layer:
Depth o scum layer:
Dimens ons of cesspool:
Materia s of construction:
Indicat n of groundwater:
inflow (cesspool must be pumped as part of inspection)
Comj1dition
s:
(note of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRI
(lo a on site plan)
Mate ials of construction: Dimensions:
Dept of solids- _
Com ents:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 04/25/97) Page 8 of 10
s
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 1 1 8 Capt Lij ahs Rd, Centerville
Owner: MCCnrmiCk
Date of Inspection: /j
Depth to Groundwater Z6 Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observation of Site (Abutting property, observation hole, basement sump etc.)
/Determine it from local conditions
✓ Check with local Board of health
Check FEMA Maps
Check pumping records
Check local excavators, installers
Use USGS Data
Describe in your own words how you established the High Groundwater Elevation. (Must be completed)
(revised 04/25/97) Page 10 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 1 1 8 Capt Lij ahs Rd, Centerville
Owner: MCCOrmi Ck
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
�iYZ°
f �
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� J
(revised 04/25/97) Page 9 of 10
No ...... Fimic ....................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............OF........... '. .r- ...........___----------------------
Appliration -fur Miip ial lVarkii Tomitrurtion Veruiit
Application is hereby made for a Permit to Constru � ( or Repair ( ) an Individual Sewage Disposal
System : . Ares . � .Location-A.dd.......0 : r.. � ,
-------------------------------------------
or
Lot No.
--------..-a; - . ._..... -------------------
Address
................................ -••--•-----•........_...--•---------•-•---...----•-•..........-•----------......---••••-----------
Installer Address
UType of Building _ Size Lot..� ....Sq. feet
Dwelling—No. of Bedrooms._..._.....(:71}----------------------Expansion Atti Garbage Grinder {.e1f6
C14 Other—Type of Building ---------------:_:___'..._ No. of persons------------- ........... Showers ( ) — Cafeteria ( )
dOther fixtures ---------------- ------------------------------------------------•-•-•--------------. ---.-.-----•----.------.--------------•----•-•-----------------
WDesign Flow............: t,)....................gallons per person per day. Total daily flow..... .... :.................gallons.
WSeptic Tank—Liquid capacit,�allons Length---------------- Width.................Diameter................ Depth:_-------•----
xDisposal Trench—No. .................... Width---------------------Total Length.................... Total leaching area--------------------sq. ft.
Seepage Pit No..-.---/-------- Diameter��`--_8-------- Depth below inlet.................... Total leaching area-------_ --------sq. ft.
Z Other Distribution box ( ) Dosing tank ( )- ep- JnC fir— - S- 2e d 7 G
aPercolation Test Results Performed by-------------------------------------------------------------------------- Date--------------------------- -------•---
a Test Pit No. 1................minutes per inch Depth of "Pest Pit.................... Depth to ground water...----_-.__._-..-------
(_, Test Pit No. 2..........:.....minutes per inch Depth of,Test Pit-------------------- Depth to ground water.-.-..---------.---_----
G
--------------« - -•-------------t® j I.....-----._._......_.................
x Descrtptign.of Soil = = ; ' C `'�%CbY -� '±.�--a ------.- ----------------------------
�-
c.� ----------r' 7 — G �
We ;.�� d ` ,�6 r �/Lf.�l.� -•-••�-'----A , .---•------------------------_.
x
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 Article XI of the State Sanitary Code—The undersign r per . rees not to place the system in
operation until a Certificate of Compliance has been i e the boa d of health.
- ---_-- � c
-76
Application Approved By. {'�'�' ----- --- - --- - -- ✓.._d ..�' . -•--- =�---
'.fit '"
(J6' Date
Application Disapproved for the following reasons----------------•---•---•----------------------•-•-----------•---•-----•-----------------------------------------
--------------------------------------------------------------------------•-•-•----•-----
Date
Permit No. Issued . Date
-------- ---------------- ------ -----J
7�
No.. ..... FE$..... Q.....................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....._......OF...........�_� = .c2" e"
_.. ................ ...................................................
Appliratinn -for ]i�ipuiittl Workii Cnnnitrnrtiou Prrntit
Application is hereby made for a Permit to Construct ( •)or Repair ( ) an Individual Sewage Disposal
System at/,
.... _-/f.��. ...I..o r...........� ----_.__
............................................................ _ __. _ _......._.__.._.........._........._.._...._.._.______._............____
Location-Address or Lot No.
Owner.. Address
Installer Address //�
Type of Building Size Lot-._/____---- feet
U Dwelling—No. of Bedrooms----------- ......................Expansion Attic (X Garbage Grinder
aa4 Other—Type of Building ___________________________ No. of persons.---------- Showers ( ) — Cafeteria ( )
0.1 Other fixtures ----•----•--------•-----------
W Design Flow..............1'�_ ...___.__..._.........gallons per person per day. Total daily flow______:'��dc'_-___-------------- gallons.
WSeptic lank—Liquid capacit�6l'iallons Length________________ Width................ Diameter---------....... Depth--.._.----._-_.
x Disposal Trench—No. .................... Width___-_:____--___-.-._ Total Length_.__________----__ Total leaching area...............-----sq. ft.
Seepage Pit No_____________________ Depth below inlet..................... Total leaching area------- ..........sq. ft.
z Other Distribution box ( ) Dosing tank ( ) - O "''= /JL•
aPercolation Test Results Performed by------- ----------- ------------------------------------------------------ Date---.-----------------------------------
,� Test Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water...___._-.__.__._-._---.
LT. Test, Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water_-._-.-_____________---.
P4 -------------•-----------------------------••--------...--•---------------.-----------------•-..............................................................
G Description of Soil-----_' -
--------------------------------------------------•------------------------------------------------------------------------------------------------ ---
U ------------------..............................................................................................................--------------------------------.-.-------------------------------
W �
x -----------------------=-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
V 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 Article XI of the State Sanitary Code— The undersigned-fairther'agrees not to place the system in
operation until a Certificate of Compliance has been issu�by the board of health.
moo -- /
Signed = / '-' '- Da
Application Approved By----------------------------------------------- Ye' -
Date
Application Disapproved for the following reasons:--•-••-•------•--------------------------------•----------------------.---------------------•--------•----------
.............••--•------------....-•---•---•-----.....----------..__......•-•-----------------------
Date
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......: <..�.................OF...........
............................................................
Trrtifirate of 0.1.nrmplianrr
THIS IS TO CERTIFY, That the Individual_Sewage Disposal System constructed ( )—o-r-TRepaired ( )
by ------- ---------------------------------_--------------- r..--------- . -----..........----------------------------
..- / Installer �--
at...-----.��_,_�--=�---....-- --- r�`� -: C ,. r Y---___ '1' ---------------
has been installed in accordance with the provisions of Article XI of The State Saliirtary 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-------.- - -------- / -- ----- :---------------------- Inspector.-I
THE COMMONWEALTH OF MASSACHUSETTS
(1— 6 �-`� BOARD OF HEALTH
I`ll el
No......................... FEE...................
Dinpviittl��_.�.-----vrk ��an trnrtinat rrmit
Permission is hereby granted........
`'%'l _._.. ".r ,- ` r
to Construct ( ) o`r�epair ( ) an Individual Sewage Disposal System
at No................
Street
as shown on the application for Disposal Works Construction Permit No---------------------- Dated---/._...._-_=_-__-_._-----..........
..............•--....----•-....--••- ......-•-
- - ----- ----------•---•-••-•----
DATE. / .... ... ......... ...--------_..._.._.._.._.............._.. Board of Health
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS -
L CQT10N ' . SEWD,C.4E PERMIT QO.
1W TALLER 5 1J&ME ADDRESS
BUILDERS 1.1 &MF- e, ADDRESS
DN,TE PER"VT ISSUED. — — — — —
D A,TE COKAPLI W icE ISSUED : — — —
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LOC,4 T/p/V CE.v /2ViLL o c /o '.�JZo,t•/ x'a vnl�4 /cat/ .Q•vra
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�$ OC/TLETS� AND Z—aACAI/n/G .a/T
TO E3E aF .�E/�/FO,�CED C O.VG.2ET
CONC2E TE ST,eE/c/G77� 3000 ;Q�/ M/iV.'
E.L�tf- C EAJ- -�� 1212 1VE STEEL ,. 20000
Y C. 10. SA/O•�T /NG
. . of�r -/O .LOADING
/4 TO�y LANE �� ti?p.+� \r`` pe/vEWQY n/OT TO E3E LOCATED
OVE,0 SYSTEM U/vLE55 V- 20
DE A/A//S , /-ILt SS, ZEE S/GAJ L OA nlAvG I S USES.
Fl; 7-/G'h! LCJCAT"/oAj /6
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oaG��� ASSESSORS MAP : I� NOTES:
TEST HOLE LOGS
PARCEL : I�
;� awFo 1) THE INSTALLATION MUST BE IN SUBSTANTIAL COMPLIANCE WITH
r H QC� I ao FLOOD ZONE : �p�( � R--� SOIL EVALUATOR : D. Megec "'HIS PLAN, 1995 MASSACHUSETTS TITLE V & TOWN OF
WITNESS : Her �)I BOARD OF HEALTH REGULATIONS.
k90 CO—imRMAN T RQ aCy REFERENCE : g�'- l� l�S DATE : - p, 2) THE INSTALLER SHALL VERIFY THE LOCATION OF UTILITIES,
'Pt7SI G J ASTH D p �'L2 PERCOLATION RAT Z MIN jVl(4+ od SEWER INVERTS AND SEPTIC COMPONENTS PRIOR TO
Ujp _ GL `f7 col 1,l1 LTI� = o �( �,� �` INSTALLATION.
Q ° /A
TH- I �� TH-2 - THIS PLAN SHALL BE USED FOR SEPTIC SYSTEM INSTALLATION
ook � Q� �oQ°vQo •, � _.. � GL -(a3•y"( U �1,:•�o3 .S8 3)
' 1 I '' /) S ONLY, AND SHALL NOT BE USED FOR PROPERTY LINE
I 1 _L CFI (��' v �� Pam` �id tG- W VJ C.�>- JU v�'� cr�S I-/'rp a y�A`v f'j LOAM 5 DETERMINATION.
p� r� I ( A
Qo qp Ay\�� ��° y r 4) ALL PIPING TO BE 4" SCHEDULE 40 @ 1/8 "/ FOOT. (UNLESS
SPECIFIED OTHERWISE)
LOCATION MAP (0 T� � �' �oy�sl� —�I 33 Z� IDy�s/� �pl•S� 5) THE DESIGN OF THIS SYSTEM DOES NOT ALLOW FOR THE USE OF A
�"L Y /LoAm) CI S"-o l /�Ar�1 GARBAGE DISPOSAL.
6) SEPTIC TANKS AND DISTRIBUTION BOXES (WHEN INSTALLED)
NI ED 1 V,M1
MUST BE PLACED ON A MECHANICALLY COMPACTED BASE OR ON
� M E pi vrl� A BASE OF 6"OF CRUSHED STONE.
7. rLN� G� tcrt SIT - tQe- -PuA?.f , ! o.
o f��, SZ•' Alo CAW 04b3. �1"o Pee- Tpne' V _
. ---yj ' �•�------ �y �� �U �l<t i� ,c.� wJ 1� I SO aF
` SEPTIC SYSTEM DESIGN
I �8 0/0 /SO' OF-
FLOW ESTIMATE
IU�. T�T
b--VARt- N.f .. ..- l?�MM L off- 7�'�vN GF l Rol
I I I 5 BEDROOMS AT ( IU GAL/DAY/BEDROOM - �330GAL/DAY
t�_v-.. b�- �f�1�',--T�t ►"c.�(� ULf�--i t orv5 1Z���VI I?,�p,
l � SEPTIC LANK
E1- I 1 f l I) .Q_- 1gC C /fit s (��KYt Et,� 7U Pv N'.ZC� (�8 A,0e P-�
` I 3�OGAL /DAY x 2 DAYS - �'�U GAL IZ, dollG�e r=v sv_- cep
fi t, p1� USE �.rJGALLON SEPTIC TANK— F-VST7�V� wf / Svv
) �' �/ TAnile- Ir— ►=<I t L£✓> , UlQivi 9 fl i; oK �x Y��1ZsI �
C,tJ J I SOIL AB:;ORPT I ON SYSTEM
� - � �,��� ►rJ F I�T�i-Ulz- �s2� �N rt� N -Zo Loy--�a I
- - _
11 (r I SIDE AREA:
2 -f- 10, 2,j -
i BOTTOM AREA: 3o x o x o, 711 = ZZ 2
�4 � � K ►1<� I►► � 3 yv. y U ��!�
SEPTIC SYSTEM SECTION 7(Y-
I LIu ° E U F � �. • Co5. 1('0
I i I If> s n 1 (� Cn"G1L �tr►15�1 Brack.. � M►/ ,� �}�'InsP. o�-
fzt I �J ►I wkM "�,f-'J.askc EL. 6/ °
D-BOX
I�OQO GAL wxk/ 4c st
a
' SEPTIC TANKflevlwe
� 117 :2 ilk : bF
L A� �.r .. "ter
P F—P C H-1 n� (OS,5 SE
I E '�� `� - �77� ��= T�s '• S�-08
I ! , No. 1140
k ,�.9 "\ . iU6 waskPJ SITE AND SEWAGE PLAN
Sfe>►e LOCAT ION : H6 01 P l_I t) IV Foltb ,-
�y J>Ljiale PREPARED FOR
N
U)F t v f c nl
� !
�r�n► SCALE :
DARREN M. MEYER, R.S.
&�� I P �1 -- -_a ... -- ��l DATE : '()? Z 7 06
P.O. BOX 981
z EAST SANDWICH, MA 02537
z
Z'll fb� L DATE HEALTH AGENT Ph: (508) 362-2922