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HomeMy WebLinkAbout0138 ELLIOTT ROAD - Health E= 2�48 OTT ROAD, CENTERVILLE 57 F•----ter--- -- ---- — — ------ � -------- --------------- .5meMeJ� UPC 12534 ' No.2_ 153LOR ��r HASTINGS. MN Ile YL nJUN � BORTOLOTTI CONSTRUCTION,INC. 765 WAKEBY ROAD,MARSTONS MILLS,MA 02648 CA 508-771-9399 508-428-8926 FAX: 508428-9399 ~' $ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIF ATION Property Address: /3ff Date of Inspection: S Inspector's Name: CJ; O,wnpr's Name and Address: CERTIFICATION STATEMENT: I certify that I have personally inspected the sewage disposal system at this address and that the informa- tion reported below is true,accurate and complete as of the time of inspection. The inspection was per- formed based on my training and experience in the proper function and maintenance of on-site sewage disposalXstems. The System: Passes Conditionally Passes Needs Further Ev ation By a cal Aproving Authority Fails Inspector's Signature: Date: The System Inspector shall submit a copy of this inspection report to the Approving authority within thir- ty(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: A)SYSt/'1;,9M 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. B)SYSTEM CONDITIONALLY PASSES; One or more system components need to be replaced or repaired. The system, upon comple- tion of the replacement or repair,passes inspection. Indicate yes,nor,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 sep- tic tank is replaced with a conforming septic tank as approved by The Board of Health. Sewage backkup 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): 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Broken pipe(s)replaced Obstruction is removed Distribution Box is levelled or replaced The System required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of The Board of Health): Broken pipe(s)are replaced Obstruction"is removed„ " C)FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Board of Health in order to determine if Conditions exist which r o Co require further evaluation by The protect the public health, safety and the environment. the system is failing top p Y 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 FUNCTION- ING 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 water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is with a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 Feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 Feet but 50 Feet or more from a private water supply well,unless a well water analysis for colifonn bacteria and volatile organic compounds indicates that the well is free from pollution from the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. D)SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of efluent 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 clog- ged 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 -2- s SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) 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)LARGE SYSTEM FAILS: The following criteria apply to a large system in addition to(lie criteria above: The design flow of a system is 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following' conditions exist: The system is within 400 Feet of a surface drinking water supply The system is within 200 Feet of a tributary to a surface drinking water supply The system is located in a nitrogen sensitive area Interim Wellhead Protection Area . (IWPA)or a mapped Zone II of a public water supply well. The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Check if the following have been done: __4e::ffumping information was requested of the owner,occupant, and Board of Health. !"Hone of the system components have been pumped for atleast 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. __ALAs-built plans have been obtained and examined. Note if they are not available with N/A. __jZFIte facility or dwelling was inspected for signs of sewage back-up. __&��fhe system does not receive non-sanitary or industrial waste flow. __,Zthe site was inspected for signs of breakout. _/All system components,excluding the Soil Absorption System,have been located on site. T fiThe septic tank manholes were uncovered,opened,and the interior of the septic tank was in- spected for condition of baffles or tees,material of construction,dimensions,depth of liquid, _4eptl1 of sludge,depth of scum. he size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. -3- 1 "a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST(continucd) The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEM INFORMATION / FLOW CONDITIONS RESIDENTIAu Design Flow: M) allons Number of Bedrooms:_ Number of Current Residents: Garbage Grinder: Laundry Connected't'o System:v&I Seasonal Use: Water Meter Readings,if ilable: Last Date of Occupancy:(&,t/7/Y-e?v4- COMMVIRCIAIANDUSTRIAL& Type of Establishment: Design Flow: gallons/day Grease Trap Present: (yes or no) Industrial Waste Holding Tank Present: Non-Sanitary Waste Discharged To The Title V System: Water Meter Readings,If Available: Last Date of Occupancy: OTHER: Describe) Last Date of Occupancy: r GENERAL INFORMATION PUMPING RECORDS and source of informat' n: System Pumped as part of inspection: .a If yes,volume pumped: gallons Reason for pumping: TYPE F SYSTEM: Septic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy Shared System(If yes,attach previous inspection records, if any) Other(explain): APP TE AGE of all compon,e ts, date installed(if nown)and source qf informa ' w T Sewage odors detected 4hen arriving at the site: AIQ -4- J SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C GENERAL INFORMATION (continued) SEPTIC TANK: (/ Depth below grade: Material of Construction: —LzConcrete metal FRP Other (explain) — Dimisions:$;.S X C� `.ram' Sludge Depth: AX9.7 je Scum Thickness: Distance from top of sludge to bottom of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation t utlet invert, structural integrity,evidence of leakage,etc.)T,L'S C--. e� 101) GREASE TRAP: Depth Below Grade: Material of Construction: concrete metal FRP Other (explai n) — — — Dimensions: Scum Thickness: Distance from top of scum to top of outlet tee or baffle: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) TIGHT OR HOLDING TANK:.d/-d Depth Below Grade: Material of Construction:_concrete_metal_FRP Other(explain) Dimensions: Capacity: gallons Design Flow: gallons/day Alarm Level: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: Depth of liquid level above outlet invert: , ` ,r Comments: (note if level and distribution is equ evi -lice of solids carryover,evidence of igakage in or out of box,etc) ozr ' yC l PUMP CHAMBER: Pump is in working order: Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) -5- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SOIL ABSORPTION SYSTEM (SAS): (Locate on site plan,if possible;excavation of 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: Comments: (note condition of soil, si s of hydraulic failure level f pondi ondidon of v etation, etc:) cl CESSPOOLS: � Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of Cesspool: Materials of construction: Indication of groundwater: Inflow(cesspool must be pumped as part of inspection) Comments: (note condition of soilk, signs of hydraulic failure, level of ponding,condition of vegetation, etc.) PRIVY:: Materials of construction: Dimensions: Depth of'Solids: Comments: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, . etc.) -6 - N SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references, landmarks or benchmarks. Locate all wells within 100 Feet. I _U0IU7- O PL C�SL� 17 . 1 U L'O r DEPTH TO GROUNDWATER: i Depth to groundwater: / Feet Method of Determination or Approximation: �'t�,Pi4jc' ✓oiy Gt�J P dT e—, /o / �i -7- TOWN F BARNSTABLE LOC:A iIOIN ' �" SEWAGE # V'.s.L'AG ASSESSO ' MAP& L T O'7, OWt �V FAT_ s° � AME&PHONE NO. SEPTIC TANK CAPACITY 66 LEACHING FACILITY: (type) (size) NO.OF BEDRO. MS BUILDER R PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: p Maximum Adjusted Groundwater Table and Bottom of Leaching Facility / S 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,,feee�et of leac/hing fac'' %� Feet Furnished by&Jzn/_(O ,., � ��� �� �9 0 ��r �, II -Y No. 3 - THE COMMONWEALTH OF MASSACHUSETTS BOARD....... !-ZEAL � �Q.�`...............OF....... ....... ..... --- Application is hereby, a�a� for it _ons ruct epair ( ) n dividu Sewage Disposal yst at: �^ Location:• ddl�es' ........... ��................................... ..............1.!.... Lot[p�?.... ..........:.... Owner/� ,ddress , W 'pl,ra�'Z l.. ..C' ? �1���' o ... .........4A?,%�?J.j.0...... I�Q. ... .M.A_....................... Installer Address �pp�� Type of Building Size Lot..``OO,.A8O...Sq. feet Dwelling—No. of Bedrooms...........3............................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons,......................... Showers ( ) — Cafeteria ( ) dOther fixtures ..............I.................................. W Design Flow................�45.. ...............gallons per person er ay. Total ail}}'',,fl�.�ow__._._. ..- _. . to s. WSeptic Tank—Liquid capacity..` allons Length...= . Width.�_�'_l(_•1. Diameter................ Depth.' 3- W Disposal Trench—No..................... Width.................... Total Length....... Total leaching area____................sq. ft. Seepage Pit No. ...... .. Diameter..______....... Depth below inlet..... .......... Total leaching area..�...sq. ft. Z Other Distribution" ( Dosing to Percolation Test Results Performed by---------- .................. Date...-.7.��.. .__.. 4 Test Pit No. 1.../—rZ ..minutes per inch Depth of Test Pit___ ......... Depth to ground water--- .�......... (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-.-._---_---------_-__. W . Description of Soil-----.0_' 2..1-1-�ZR.v..--- --- ....... . .....2-- -�Z V ----------------------- •------------------------------------------------------ .-_..:------------------------------------•--•--------------------------------------------- ---------------•--------------- W UNature 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 TITLE 5 of the State Environmental 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. Signed .......... -- ................ . . .......... -------------_-----------4.... ------------ .......... Approved BY ©. �! - .. .. ........ ......................... ......... ..-......-. to ..._ ---3 Application Disapproved for the following rear r. ................................ ...................................... ......................................... ............................................... ------ . D..e- --- - -- - - -- ...--- -- Dace Permit No. .--- ------ ............. --------------------- Issued .... �. ... c�� No................_....... 5 7-- � Fps.............................. THE COMMONWEALTH OF MASSACHUSETTS BOPe R® F- F-1 E LT c: '1.. OF.................�' -. y-•------------------ ApplirFafion for Diiipwi al Works Tomitrnrtinn ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Systen} a' `- Q. .....---` 1. ...........• - Location-Ad s or Lot -------•--•• -.-------•-1 ..... T �111. 11 �. .............. Owner Idare5s W Installer Addressf" d Type of Building Size Lotl�;.AeQ...Sq. feet U Dwelling—No. of Bedrooms.............................. .. .....Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fix= ----- - ---- - W Design Flow.................47:__..__..___.__ -----g-allons---- per person er8-- y. Total ail,Y flow.__.... _.. __.. 1 s. WSeptic Tank—Liquid capacity__Vrallons Length ._= . Width. _-'1_Q Diameter................ Depth.- ---- x Disposal Trench—No..................... Width.................... Total Length......__........... Total leaching area--------------------sq. ft. Seepage Pit No--------- Diameter.._.__._------- Depth below inlet.................... Total leaching area..ZP.0...sq. ft. Z Other Distribution box ( ) Dosing to ( 1/1 `4 Percolation Test Results Performed by.......... ------------�. ...................... Date____7 . ,.a Test Pit No. 1___/.7,-_minutes per inch Depth of Test Pit___1.Z......... Depth to ground water...... �_l..l_......... Gt, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water..._--_____-_-_.-_____. a •-•••-- •---••-• .......... ..... - ------ D Description of Soil...... ......................... ............ . .....E.:` E---•- - mi x . -• -• ••-•---- •. -•................ V --------•-•---•••------•••-•---•------•-•-••••••--•-••••...-••••-•--•--•---------------------••-•-•-------------•••-•-••-•••---•----•--••••-•-•----••-•••--•-••--••-•----------•---•--------••--••. W ------------------------------------------------------------------------------------------------------••--•--••......---•••-----••-----••--------••-------•-•-•------•---•--••--•--•-••................ 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 TITLE 5 of the State Environmental 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. ` Signed ............... ................... .................`.'...................................�-............. ---------------------/........_..-- -- / Date• '7 �. ApplicationApproved B �:...�.....�.... ` .......................................-----------------...!.. /----.....-------- ----------- /pP pP Y ... e Application Disapproved for the following reasons- ------------------------------------------------------------------------............................................................... I f -------------------------------------------- - ......--------- t � , �- •--„� � • �-'"/ �, .� (� / � Dace Permit No. f ! -.j.................... Issued /� ,/ /-..-.. Dace ' THE COMMONWEALTH OF MASSACHUSETTS BOARD'OF.IHEA TH -----------...i.-�.�.'�. ....--.... OF -------� .Jl\:' ,C,J-l.'..... -- 4._ &rtif rate of Tantylianc.e THIS IS TO,,CER-TIFY, That thpIndividual Sewage Disposal System constructed ( ) or Repaired ( ) by ' �-► t ) r _ . /---------- ........... ..------ ........--- ------ ---- ---------------- ---- -------- has been installed in accordance with the provisions of TITLE 5rof_The State-Environmental Code as described in the application for Disposal Works Construction Permit No. ..;.yf........ ........ dated ................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE......" .... ....................................... Inspector . 2 �. ..................... 7. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTHY/�1 _...--- No......................... J ...............:..�:...'..✓ ::;... ....OF.---....!... /\:..``.-✓ 1` .f.a'..:'......x:......:......... FEE .. Permission is hereby granted........%.Fy... ...._. ...............' to Construct (�`.'t) or Repair ( •)-an Individual Sewage Disposal System'�,-- atNo.............................. I ... ° ' = -................ --'- -- Street' . as shown on the application for Disposal Works Construction Permit No..................... Dated.......................................... -----•• . Board of Health DATE................................................................................ FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS -: T�ATA , 1 + S1�16e� F'tILY 3 $EDQa6.Ms �a 6A�F3AC .:G1zITJ E>Z _p �( emu/ 'kilo . SEPi l C . TA►J� 30.x l 5O . 49S 6pz:>' UGOno T, . � I q P T I oCO, �Ac.. '%I st'arJE r # AWeA T l Sa sf= BOTTOM Ala _ so SF4 , : }� t�.".a r 23 �� �' �� 014.5ej7D, TV (> m TOT�NL tr=516W - A-'z TOTAL DA!lyK/ - .......i -r s rA Mier � t T-"E240LATtoN QATE. pt, .:AR-0 i' TJ`.E R r• J I Sl:lTdAI 4419 Zoe Ak 5T 7''o'P�5 :i t "` CLE- =49 F�=47 14$ 1 F6-48 lv A.t// i s---Q7(.+ r� "'777:T�f7�►�� z MKT 4,0 a5 sS.G GAt sS.s as loap` iur �S B,C9C ¢ GAL s _: 7AN4 ' 1 - `rl f' Mtn 34-1 Vz !-4. ; { --------------- 39 SI(ALLY 8E `Z D + MAT, o r _ /E1opq� PZCF ICezi'rFt® Pc or PCd N go ----------------- sin ;.. _ # i^:` • .• I-CTioN : y��J S t57 �o�rE�...1!5/-:3,5-P-4478 SG ,LE-, DATE- , c_. 1 �c� 24- OPn PLAN R-ERF�JC�6GzOFY Tf1AT '74E FD0Nx 'A' ►h J_ a1owN NE2EpN coMTU lS wrrµ . St UtJE L 2Z A+tD 15 l Loci tJEov<_ :atil, RL . �. /� U i` 1 Z� $a XTEa. NYE 415 !J (S Not- ?ME > OiJ tiN IcJST vWtWt � � �1D THE O�5efs � Ul,�. :IJU(' � o . � v I L E,061 N�Elzs u5 T'o .CST BL1�5(� ' , F St�2vic 1 >C MA -y u ups i. 44 P cA WT 2EEZh-,z..: � L ! 9 '1 Q f� 42 to / J, ' - 0. uj WL t_ ox Y _ p --r- _ A 4 Ilk Lb cx ZVN L r- 4 t al •� vt � � �p �_� _� � o Q �' z O �9 � �O � 31_ z J F rl Sze � pd o F � LLZd B S- cc F {« �> � � rcr— 1—'-L`�ry V t► 3 F-F � I I °� PETER' I SUUIUAI l I 29733! // x a 446 , I - 12 ' � F i I ` I , Vj �UT7 M Wll.LI I AM . G� sir i �F 2 -S .�/�,�; ��? wVv I � { r I � Y3 17 AA fi5 AJ • I I. �.. I I ' I' � I I I �..71 t E -r i 4d a �. `'!`�r8 i ev I i I f I � �; �� �Z.•Z .q=Z4 . : .. ;.�'c.E.er�F� .y r-��or-:.o��✓ r b 3G,o �ocQrro/vl �y,Q I ' Phi JA;v, /a;L�- '_.`� G'-wr&' oz !'q4X.Te g NYC; ;4�5/l�,fE7"d�CY ,C��QU/��•M�NrS d� 7fr� , , .�6/sr�. --;•��ac'Qr,E.o w�r'H/y T.U�• �1"c�oG!_..Q/�V. �..r � ;�:j a, �; I� , �_ -� ' ;.. �Sh�?lYi!/fj�E.eE�iV�,j�4UG17 a6 'USE Ta , } I I _ I I b , i r . X I N 2� i ? , r 71. I .✓' , ' , K L i, ti �{ II 5 V/ t IJ I a I f i �. i . I , I i l I E1 o�` r i p W ILLIAM aN 1Cf, •- I.�. I NYE w; No 19334 41 ST su PETER SULLIVAN l7 v is � II NO. 29733 . i OF ��ISTE��,t��e I ' r a ;: OCATION LOT COPPER LANE NO. 4 7 �I ILLAGE HYANNIS DATE_5 8 '35 PLICANT BAYSIDE BUILDING CO. , INC.-BRIAN DACEY FEE $35 •b0 DRESS. P.O BOX 95 CENTERVILLE, MA 02632 TELEPHONE NO. (Non-refundable NGINEER BAXTER & NYE, INC.-PETER SULLIVAN _TELEPHONE NO. 428-9131 • ATE SCHEDULED - 95 10 % ®O (Applicant' s signature SOIL -LOG .. `` , UB-DIVISION NAME DATE �Uc_ 3c) TIME XPANSION AREA:' YESY NO asc-C ENGINEER * QWN WATER .PRIVATE WELL BOARD OF HEALTE R_L SC-® EXCAVATOR KETCH: .(Street name, etc. ,dimensions of lot, exact location of test holes and 'percolation tests, locate wetlands in proximity to test holes) . . ' NOTES : � _&,55 • LO-T ZZ E, q jAee0 � A� �J, 1" j e PERCOLATION RATE: TEST HOLE NO: ELEVATION: TEST HOLE NO: ELEVATION: 2 U� �.G�«-2 . 3 3 _ 4 4 5 16 A"v 5 6 6 7 7 g 8 , 9 9 10 10 11 11 12 t2 12 13 13 14 (�D V�11°� 14 15 15 16 16 M , SUITABLE FOR SUB-SURFACE SEWAGE: LEACHING FIELD ACIJING PITS LEACHING TRENC Ste. UNSUITABLE FOR SUBSURFACE SEWAGE. REASONS le NOTE: ENGINEERING PLANS MUST SHOW NUMBER ASSIGNED ON PERC TEST APPLICATION ORIGINAL: COMPLETED IN ENTIRETY BY P E AND RETURNED TO BOARD OF HEALTH COPY: RETAINED' BY APPLICANT / -OF PARNSTABLF F LC SEWAGE # �3'LOCATION . �- � ��. VILLAGE0,pj/) , le- ASSESSOR'S MAP 6z LOT—Wg-O-"-7 --0/0 INSTALLER'S NAME & PHONE NO SEPTIC TANK CAPACITY /000 GJ�� LEACHING FACILITY:(type) �� C /� (size) NO. OF BEDROOMS PRIVATE WELL O PUBLIC WATER BUILDER QWNER C ` DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No a FR&o q O �qa y�