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Commonwealth of Massachusetts ►.' a a '' 1 :35
fµ Title 5 Official Inspection Form -
! i�l Subsurface Sewage Disposal System Form -Not.for,Voluntary Assessments• ,
420 Elliott Rd
Property Address
Jeremy Morgado
Owner Owner's Name / _
information is
required for every Centerville-V, MA 02632 10-14-20
page. City/Town State Zip Code Date of Inspection
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.
A. Inspector Information o
Shawn Mcelroy
Name of Inspector
Upper Cape Septic Services
Company Name
P.O. Box 73
Company Address
East Falmouth MA. 02536
City/Town State Zip Code
508-495-0905 S13971
Telephone Number License Number
B. Certification
I certify that:l am a DEP approved system inspector in full compliance with Section 16.340 of Title 5
(310 CMR 15.000);I have personally inspected the sewage disposal system at theproperty address listed
above;the information reported below is true, accurate and complete as of the time of my inspection; and
the inspection was performed based on rimy training and experience in the proper function and
maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that
the system:
1. ® Passes '
2. ❑ Conditionally Passes
3. ❑ Needs Further~Evaluation by the Local Approving Authority,
4. ❑ Fails
10-14-20
Inspector's 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 form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: 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.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection- Form
i>-1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
9 p Y ry
420 Elliott Rd
Property Address
Jeremy Morgado
Owner Owner's Name
information is required for every Centerville MA 02632 10-14-20
page. City/Town - State Zip Code Date of Inspection
C. Inspection Summary ,
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes: t r
® 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:
System is in good working order with no sign of failure.
2) 'System Conditionally Passes:
❑ One or more system components as described in the "Con ditionalPass" 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):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection, Form
14 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1
420 Elliott Rd
Property Address
Jeremy Morgado
Owner Owner's Name
information is required for every Centerville MA 02632 10-14-20
page. City/Town State. Zip Code Date of Inspection
C. Inspection Summary (cont.) r
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms arerrepaired.
❑ 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 `-EIN ❑ ND (Explain below):
❑ • obstruction is removed ❑l 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):
3) 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.
a. System will pass unless Board of Health determines in accordance with 310 CMR
16.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18
c Commonwealth of Massachusetts
;wM1 Title 5 Official. lnspection .Form
I,I Subsurface Sewage Disposal System Form =Not for Voluntary Assessments
71
� h
420 Elliott Rd
Property Address
Jeremy Morgado x
Owner Owner's Name
information is required for every Centerville MA 02632 10-14-20
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.) . "
❑ 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
b. 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 tankandasoil-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 aseptic 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.
c. Other: ►
4) System Failure Criteria Applicable to All Systems:
You must indicate "Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® 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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
a Title 5 Official Inspection Form
ht Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
420 Elliott Rd
Property Address
Jeremy Morgado
Owner Owner's Name
information is required for every Centerville MA 02632 10-14-20
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® 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 Y2 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 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 water supply
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. [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.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10;000 gpd.
El ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems:To be considered a large system the system must serve a facility with a design
flow of 10,000 gpd to 16,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section CA. .
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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18
c � Commonwealth of Massachusetts
Title 5 Official Inspection Form .
Id
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
420 Elliott Rd
Property Address
Jeremy Morgado
Owner Owner's Name
information is required for every Centerville - MA 02632 10-14-20
page. Cityfrown State Zip Code Date of inspection
C. Inspection Summary (cont.)
If you have answered "yes"to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate "yes" or"no I"for each of the following for all inspections:
Yes No
❑ ® 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 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?
N ❑ 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?
IR ❑ Wasthe 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)]
r
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18
s Commonwealth of Massachusetts
r1 - ,3, Title 5 Official. Inspection Form
i��
� phi. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
420 Elliott Rd
Property Address
Jeremy Morgado
Owner Owner's Name
information is required for every Centerville MA 02632 10-14-20
page. Citylrown State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions: ,
Number of bedrooms(design): 5 Number of bedrooms (actual): 5
DESIGN flowbased on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550
Description:
Number of current residents: ,. 0
Does residence have a garbage grinder?;, ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: 2020
Date
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
s Commonwealth of Massachusetts
Title 5 Official Inspection. Form
' iIm Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
420 Elliott Rd
Property Address
Jeremy Morgado
Owner Owner's Name
information is required for every Centerville MA 02632 10-14-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. 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
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available: '
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: N/A
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts ;A-
fw Title 5 Official , Inspection Form
r�i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
420 Elliott Rd
Property Address
Jeremy Morgado
Owner Owner's Name
information is Centerville MA 02632 10-14-20 ,
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool r
❑ 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):
Approximate age of all components, date installed (if known) and source of information:
2003
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on_siteplan):
Depth below grade: 36"feet
Material of construction: '
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Good condition.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts °
r� , Title 5 Official Inspection Form
,w
h.
i,.l Subsurface Sewage'Disposal System Form -Not for Voluntary Assessments
420 Elliott Rd
Property Address
Jeremy Morgado
Owner Owner's Name
information is required for every Centerville MA 02632 10-14-20 "
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
30"
Depth below grade: feet
Material 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:
1500 gal
Sludge depth:
12"
Distance from top of sludge to bottom of outlet tee or baffle
20"
Scum thickness
2"
Distance from top of scum to top of outlet tee or baffle °
5"
Distance from bottom of scum to bottom of outlet tee or baffle
14"
How were dimensions determined? Tape
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank is in good condition with baffles installed and no sign of leakage..
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18
f
Commonwealth of Massachusetts
;w Title 5 Official Inspection Form
i Subsurface Sewage Disposal System Form !-Not for Voluntary Assessments
420 Elliott Rd
Property Address
Jeremy Morgado
Owner Owner's Name
information is required for every Centerville MA 02632 10-14-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. 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 last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. 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 per day
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection form
I� w.,
Y•iMl Subsurface Sewage Disposal System`Form--Not for Voluntary Assessments •
420 Elliott Rd
Property Address
Jeremy Morgado
Owner Owner's Name
information is required for every Centerville MA 02632 10-14-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank (cont.)
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
9. Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert 0
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.):
Good condition with water at working level and no sign of back-up from field.
,
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
fw Title 5 official Inspection Form
.+M Subsurface Sewage Disposal System Form -Not for.Voluntary Assessments
420 Elliott Rd
Property Address
Jeremy Morgado
Owner Owner's Name
information is required for every Centerville MA 02632 10-14-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) r ,
10. Pump Chamber(locate on site plan):
Pumps in working order: -' ''s ❑ Yes ❑ No*
Alarms in working order: i .❑ 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.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type: ,
❑ leachirg pits"' number:
® leaching chambers number: 5-500's
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18
Commonwealth of Massachusetts
�al
Title 5 Official Inspection Form
i.1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
420 Elliott Rd
Property Address
Jeremy Morgado
Owner Owner's Name
information is required for every Centerville MA 02632 10-14-20
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.) r }
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leach chambers in good condition and empty at inspection with no visible stain lines.
12. 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
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts I
ri Title 5 Official Inspection Form ,
hi Subsurface Sewage Disposal System Form Not for Voluntary Assessments
� I:a
420 Elliott Rd
Property Address
Jeremy Morgado
Owner Owner's Name
information is required for every Centerville - MA 02632 10-14-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. 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.):
i
• 1 � 1
\ ti
t _ _ •
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts W
�r
Title 5 Official Inspection •Form
'i Subsurface Sewage Disposal System Forme-Not for Voluntary Assessments
`rrf 420 Elliott Rd
Property Address
Jeremy Morgado
Owner Owner's Name
informati for every on is
required Centerville MA 02632 10-14-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) '
14. Sketch Of Sewage Disposal System:
Provide a view 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. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
f .
1 ` /
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AC3
0 ,3
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18
Commonwealth of Massachusetts
r� Title 5 Official Inspection Form
i i,l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
420 Elliott Rd
Property Address
Jeremy Morgado
Owner Owner's Name
information is required for every Centerville MA 02632 10-14-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 12'+
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
® Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
® Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database - explain:
You must describe how you established the high ground water elevation:
Original design plans show no groundwater at 12'.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18
Commonwealth of Massachusetts
t" Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
420 Elliott Rd
Property Address
Jeremy Morgado
Owner Owner's Name
information is required for every Centerville MA 02632 10-14-20
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch-of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
V
�03_ 6
: No. �1 _5_
�, Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS VYes /
application for ;Migpogal 6potem Construction Permit
Application for a Permit to Construct( . )Repair Upgrade( )Abandon( ) aJ Complete System 4 dividual Components
Location Address or Lot No. Owner's Name,Address and Tel.No.
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. �1• Designer's Name,Address and Tel.No.
Od1414
Type of Building: (-
Dwelling No.of Bedrooms_�7 Lot Size sq.ft. Garbage Grinder( �®
Other Type of Building ge J e—'Ite.No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow %l gallons per day. Calculated daily flow S .S2 gallons.
Plan Date W Z Z,2 42 3 Number of sheets Revision Date
Title S t047it O l 1 _
Size of Septic Tanic i5n',e9 9 Type of S.A.S.
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 Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been iss ed this B o -
Of
Signed Date
Application Approved by Date
Application Disapproved fo the following reasons _
Permit No. Date Issued
3: No. ss 4 4 r j ,;,,." Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUB IC HEALTH DIVISION -"TOWN OF BARNSTABLE, MASSACHUSETTS Yes
V
`Zipprication for Oiopogar *p5tetn Conelructton Permit r
Application for a Permit to Construct( )Repair( ✓)Upgrade( )Abandon( ) g Complete System Ck% dividual Components
Location Address or Lot No. wner's O Name,Address and Tel.No.
Assessor's Map/Parcelro�aycel `��r. ,
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
7 7/ -�13W
Type of Building:
Dwelling. No.of Bedrooms S Lot Size sq.ft. Garbage Grinder( ��
Other 'I�pe of Building J i°eee-No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow 5 2�5? gallons.
Plan Date Number of sheets Revision Date
Title S/ 7`� irC1'v! t5' L/Z D
Size of Septic Tant / Type of S.A.S.
Description of Soil,
/ /f
Nature of Repairs or Alterations(Answer when applicable) e,-
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 Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued byothts oaid of>Heh / �/
Signed !. (: r 1? Date ?/c?✓�'3
Application Approved by i f,f ,> t f�(� �/�� i., 1'g, �%/ r.r , ; Date
Application Disapproved for/the following reasons
Permit No. a �� Date Issued
---------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
(Certificate of (Compliance �
THIS IS TO CERTIFY,that the On-site Setwage Disposal System Constructed( )Repaired Upgraded( )
Abandoned( )by JDf 7��nr �'rJl�IsT'
at �'' �� t� �' �y !// Ile has.been onstructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. ated
Installer Designer
The issuance of this permit shall not be construed as a guarantee that the system function al designed.
Date 1 1 i i Inspectors. 1 i
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Zi5pogaf *p.5tem Construction permit
Permission is hereby granted to Construct( )Re air pgrade( )Abandon( )
System located at L) -G� ��%/p to J (�'. eZ`'/�G'/
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions,
Provided:Construction . ust a comp eted within three years of the date of this permit. inl�
Date: (/`J Approved by /1
TOWN OF BARNSTABLE E
LOCATION SEWAGE.#
J T aa7-/�
ASSESSOR'S MAP & LO
VILLAGE ��g*��'�' !e .
INSTALLER'S NAME&PHONE NO. �ev�s�@ � s'r 'dim"' Ya r -V,-7a f
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) iGP?f� 1.. CG� ,b.� C�� (size)
IT
NO.OF BEDROOMS S °
BUILDER OR
PERMIT DATE: `� �l✓!� COMPLIANCE DATE: ► a
Separation Distance Between the:
Feet
Maximum Adjusted.Groundwater Table to the Bottom of Leaching Facility
.�¢
Private Water Supply Well and Leaching Facility (If any wells exist Feet
on site or within 200 feet of leaching facility)
Edge of Wetland and Leaching Facility(If any wetlands exist �— Feet
within 300 feet of leaching facility)
Furnished by-
1 %v✓s✓ ��'�`'' �" �"�"".'�•
ll
� JG�rer'"► �
F
�\ J -yam°°•-�.... _.
7
LOiCA•T ION q,Ze ���`� , S GE PERMIT NO.
VILLAGE /� J � A
INSTALLER'S NiME & ADDRESS
e�iS
B UI'LDE R OR OWNER
c � �� (3ror
DATE PERMIT ISSUED
0ATE COMPLIANCE ISSUED
Qtrcr a //oclC P
�0 0 fo b
010
S ,
4 3
h
�V TOWN OF BARNSTABLE E
LOCATION ALL. fii SEWAGE # ��
VILLAGE ASSESSOR'S MAP& LOT -2_7 r/�_
INSTALLER'S NAME&PHONE NO. llov-ls/�Ata' Y'7aL
'SEPTIC TANK CAPACITY /S-Oc•� j5��z_
LEACHING FACILITY: (type) i 2V e*11,w4 64,)4#*U 6_) (size) .39 F7'
NO.OF BEDROOMS S
BUILDER OR >Gd
PERMIT DATE: 131le 3 COMPLIANCE DATE: t a U
Separation Distance Between the:
Maximum Adjusted Groundwater 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 C"47f5- G• �e.��;n�
SX.
i -
t
Z 203 �1498 832
US Postal Service
Receipt for Certified Mail
No Insurance Coverage Provided.
Do not use for InternAtional Mail See reverse
0
re Number
MPce, & P e
Postage
Certified Fee
Special Delivery Fee
Restricted Delivery Fee
Ln
Return Receipt Showing to
Whom&Date Delivered
tL Return Receipt Showing to Whom,
Q Date,&Addressee's Address
0 TOTAL Postage&Fees Is
d! Postmark or Date
0
u_
a-
i
Stick postage stamps to article to cover First-Class postage,certified mail fee,and
charges for any selected optional services(See front).
1. If you want this receipt postmarked, stick the gummed stub to the right of the return
address leaving the receipt attached, and present the article at a post office service
window or hand it to your rural carrier(no extra charge).
2. If you do not want this receipt postmarked,stick the gummed stub to the right of the m
return address of the article,date,detach,and retain the receipt,and mail the article. ,C
u7
3. If you want a return receipt,write the certified mail number and your name and address rn
on a return receipt card,Form 3811,and attach it to the front of the article by means of the
gummed ends if space permits. Otherwise,affix to back of article. Endorse front of article :o.
RETURN RECEIPT REQUESTED adjacent to the number. Q
4. If you want delivery restricted to the addressee, or to an authorized agent of the O
O
addressee,endorse RESTRICTED DELIVERY on the front of the article. Go
5. Enter fees for the services requested in the appropriate spaces on the front of this E
receipt. If return receipt is requested,check the applicable blocks in item 1 of Form 3811. ti
6. Save this receipt and present it if you make an inquiry. 1 o25s5-s7-a-o145 rn
{ t
Town of Barnstable --
: : Department of Health, Safety, and Environmental Services
• wwsreete, •
. � Public Health Division
�EDMA't� P.O. Box 534,Hyannis MA 02601
Office: 508-790-6265 Thomas A.McKean,RS,CHO
FAX: 508-790-6304 Director of Public Health
April 3, 1998
Anthony&Allice Spadafora
P. Box 93
Malden,MA 02148
ORDER TO COMPLY WITH 310 CMR 15.00,THE STATE ENVIRONMENTAL CODE,
TITLE 5.
The septic system owned by you located at 420 Elliott Road, Centerville was inspected on
January 9, 1998 by Robert Bortolotti,a Massachusetts licensed septic inspector.
The inspection of your septic system showed that your system has failed under the guidelines of
1995 TITLE 5 (310 CMR 15.00)due to the following:
• Both leaching pits showed signs of being full of wastewater effluent at some time. The
distribution box also showed signs of being full at one time.
You are directed to hire a licensed Town of Barnstable septic system installer to submit a sketch
diagram of a proposed system to the Town of Barnstable Health Division Office(Town Hall, 367
Main Street, Hyannis) that will bring the septic system into compliance with 310 CMR 15.00,
The State Environmental Code,Title 5 within thirty(30)days of receipt of this notice.
You are also directed to bring the septic system into compliance within sixty(60)days of receipt
of this order letter.
You are further directed to maintain the system by hiring a licensed septage hauler to pump the
septic system to prevent discharge of sewage or effluent into the buildings, onto the surface of
the ground,or in to surface waters.
Any person aggrieved by any order issued by the local approval authority may appeal to any
court of competent jurisdiction as provided for by the laws of the Commonwealth.
DER OF THE OARD OF HEALTH
cKean,R.S.,C.H.O.
Agent of the Board of Health
q\health\dbfiles\title5 i.doc
'EVE Town of Barnstable
Department of Health, Safety, and Environmental Services
BMWS'rA�.16319. Public Health Division
367 Main Street, Hyannis MA 02601
Office: 508-790-6265 Thomas A.McKean,RS,CHO
FAX: 508-790-6304 Director of Public Health
nL TO: �2
�3 DATE: G 3/�
I n . Mft
ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL
CODE, TITLE 5. ,�
The septic system owned by you located at 41 2 ��'�` was0 Y�i o - f2� als k
inspected on-3�') . q, 19gE- by42J---esh 80,o ' , a Massachusetts licensed
septic inspector.
The inspection of your septic system showed that your system has failed under the
guidelines of 1995 TITLE 5 (310 CMR 15.n000) due to the following:
eP bet lv O
G 1S1, Su Jam)Q [c, ®d t nL Y' a� old I n,P
You are directed to hire a licensed Town of Barnstable septic system installer to submit a
sketch diagram of a proposed system to the Town of Barnstable Health Division Office
(Town Hall, 367 Main Street, Hyannis) that will bring the septic system into compliance
with 310 CMR 15.00, The State Environmental Code, Title 5 within (1A)-fbu een days of
receipt of this notice. -.,is(0/
You are also directed to bring the septic system into compliance within thir )-days of
receipt of this order letter.
You are further directed to maintain the system by hiring a licensed septage hauler to
pump the septic system to prevent discharge of sewage or effluent into the buildings, onto
the surface of the ground, or in to surface waters.
Any person aggrieved by any order issued by the local approval authority may appeal to
any court of competent jurisdiction as provided for by the laws of the Commonwealth.
PER ORDER OF THE BOARD OF HEALTH
Thomas A. McKean, R.S., C.H.O.
Agent of the Board of Health
gVua1thk6fdaVit1c5i.doc
PAR ] Real Estate System - General Property Inquiry] Help [ ]
Parcel Id: 227 135- - Account No: 138416 Parent :
Location: 420 ELLIOTT RD Neighborhood: 48AA Fire Dist : CO
Devel Lot : 35 _ Lot Size : . 39 Acres
Current Own: SPADAFORA, ANTHONY W TR & State Class : 101
SPADAFORA, ALICE M TR J No. Bldgs : 1 Area: 2741
P 0 BOX 93 Year Added:
MALDEN MA O 214 8/
Deed Date : 080195 Reference : 9781/347
January 1st : SPADAFORA, ANTHONY W TR & Deed MMDD: 0895 Deed Ref : 9781/347
Comments :
Values : Land: 34900 Buildings : 210300 Extra Features :
Road System: 420 Index: 492 (ELLIOTT ROAD ) Frntg: 139
Index: 565 (FOX RUN ) Frntg: 122
Control Info: Last Auto Upd: 092196 Status : C Last TACS Update : 090496
Land Reviewed By: Date : 0000 Bldgs Reviewed By: ME Date : 0496
Tax Title : Account : Taken: Account Status : Hold Status :
Cancel [ ]
Press XMT for more data
Next screen [PAR ] Action [ ]
Owners Name [ ]
Road Index [ ] Road Name [ ]
Parcel Number [227] [140] [ ] [ ] [ ]
II P -
,1
t .
aa� _ •. At
6
4BORTOLOTTI CONSTRUCTION,INC. OF 49.
765 WAKEBY ROAD,MARSTONS MILLS, MA 02648 y��ryoFNjrgeZf
508-771-9399 508-428-8926 FAX: 508-428-9399
a
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM L
PART A
CERTIFIC TION
Property Address: 02
Date of Inspection: / Inspector's Nan e:
Owner's Name and Address: i O.
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
disposal systems. The System:
Passes
Conditionally Passes
Needs Further Evalu on By the Local 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)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. Ai y 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):
- l -
7 }
s .•:�, a .a .
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
r r 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:
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 FUNCTION-
ING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAATY 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 coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from
'the facility and the presenceof ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm.
D)VII
TEM FAILS:
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
shod be contacted to determine what will be necessary to correct the failure.
v 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-
god SAS or'cesspool. t }
t 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 NO,T due to clogged or obstructed
pipe(s). Number of times pumped
-2-
i
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 the 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.l1 of a public,water.supply well.,t
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: R
Pumping information was requested of the owner,occupant, and Board of Health.
✓None 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.
t✓As-built plans have been obtained and examined. Note if they are not available with N/A.
__&,fffhe facility or dwelling was inspected for signs of sewage back-up.
__.,,, The system does not receive non-sanitary or industrial waste flow.
The site was inspected for signs of breakout.
a •'rAll system,components;,excluding the Soil Absorption System,.have been located on site.
The septic tank manholes were uncovered,opened,And the interior of the septic tank was in-
Zspected for condition of baes.or.tees,material of construction,dimensions,depth of liquid,
�t
depth of sludge,depth of scum.
__�Zrhe 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-
i L
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART 11
CHECKLIST(continued)
1/ 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
RESIDENTIAL!✓ � l
Design Flow: $W Qallons Number of Bedrooms: Number•C Current Restlents.
Garbage Grinder: Laundry Connected To System:? � Seasonal Use:
Water Meter Readin s,if av 'I ble: o
Last Date of Occupan 4e
CO M .R ALJIND ST IAL:10C) _.
Type of Establishment:
Design Flow: aalionst6y . Grease Trap Preseiri .(yes or no)
Industrial Waste Holding Tank Present:
Non-Sannitary Waste Discharged To The Title V System.- --
Water Meter Readings,If Available: Last Date of Occupancy:
OTHER: Describe)
Last Date of Occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
" System Ptdi&d-a§part of inspection: `_'1f yes;`vctlu a pumped: w Rallons
Reason for pumping:
TYPE OF SYSTEM:
_JZSeptic Tank/Distribution Box/Soil Absorption System
Single Cesspool
Overflow Cesspool
Privy
Shared System(If yes,attach previous inspection records, if any)
Other(explain):
"PROXIMATE E of all com nents,date installed(if kno wn),and source of information:
7 ;7.
Sew ge odors detected when arriving at the site:
- -4-
SUBSURFACE SEWAGE DISPOSAL SVSTEM INSPECTION FORM
PART C
GENERAL INFORMATION (continued)
SEPTIC TANK:
Depth below grade: � Material of Construction: k`�conerete metal FRP_Other
(explain)
DimisionsjO,.S X& X S Sludge Depth:-T_Scum Thickness:
Distance from top of sludge to bottom of outlet tee or baffle: 3.i
Distance from bottom of scum to bottom of outlet tee or bafTte: Z
Comments: (recommendation for pumping,conditioi►of inlet and outlet tees or es,depth of liquid
1 1 in r tion to et invert,structural integrity,evi nce of leakage,etc.) 9 c.•
/i
GREASE TRAP: AIU _
Depth Below Grade: Material of Construction:_concrete_metal_FRP_Other
(explain)
Dimensions: Scum Thickness:___
Distance from top of scum to top of outlet tee or baffle:
Comments: (recommendation for pumping,condition of inlet and outlet,1ees or baffles;depth of liquid
T• , level'in relation to otitlet invert structurd integrity,`evidence of leakage,etc.) `
TIGHT OR HOLDING TANK:
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 floateswitchcs,•elc.)
DISTRIBUTION BOX:
Depth of liquid level above outlet invert: _
Comments: (note if el and distrib is equal evideWe o olids carryover,evidence of leak ge into
or out of box,etc.)
_... PUMP CHAMBER ,
Pump is in working order: y
Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.)
Rti
t'j7�
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
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 gaileries,number:
Leaching trenches, number,length:
Leaching fields, number,dimensions:
Overflow cesspool,number:
Comments:(note condition of soil,signs of hydr ulic fail a lev of pondi ,condi on vegetati n,
etc. 07—
CESSPOOLS:
Number and configuration: Depth-top of liquid to inlet invert: - t
Depth of solids layer: Depth of sc_um layer:" Dimensions of Cesspool:
Materials of construction: ' ndication 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.)
-G
I1
SUBSURFACE SEWAGE DISPOSALS YSTEM INSPECTION FORM
PART C
SYSTEM INFOIIMATION (continued)
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include ties to atleast two permanent references, landmarks or benchmarks.
Locate all wells within 100 Feet.
i
DEPTH TO GROUNDWATER:
Depth to groundwater: Z Feet
Metird of Determination or Appr ximation;
-7-
UNITED STATES POSTAL SERVICE First-Class Mail
Postage&Fees Paid
LISPS
Permit No.G-10
• Print your name, address, and ZIP Code in this box•
t'
Publ9c Health DIVISION
Town of Barnstable
P 0. Box 534
Hyannis,Massachusetts 02601
d ENDER:
v ■complete items 1 and/or 2 for additional services. I also wish to receive the
e+ ■complete items 3,4a,and 4b. following services(for an
■Print your name and address on the reverse of this form so that we can return this extra fee):
.. card to you.
■A��f this forth to the front of the mailpiece,or on the back if space does not 1. ❑ Addressee's Address
` ■permit.
Receipt Re uested'on the mail piece below the article number. at
d P 9 P 2. ❑ Restricted Delivery rn
@The Return Receipt will show to whom the article was delivered and the date .,
c ; delivered. Consult postmaster for fee. °
o.. d
Article Addressed to: 4a.Article Number
d 017 �� c
4b.Service Type
❑ Registered 31 Certified ¢
❑ Express Mail ❑ Insured c
cc ❑ Retum_Recei t for Merchandise ❑ COD
z l 7Pfe o! �uffeliviiN` a.
0
5. eceived ht Name) 8:A�diessee4ddre"ss(Only if requested c
W �anfe�isdj 4 F
c i n s rAgent) �jb `��
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PS Form 3811, December 1994 to2s95-97-a-om'is Domestic Return Receipt
No.......... Fims..V..........................
THE COMMONWEALTH OF MASSACHUSETTS k. u
BOARD OF HEALTH
OF.......... .....................................
................ .-�
Appliratiou for Bh4paaa1 Workii Toastrurtiou ramit
Application is hereby made for a Permit to Construct ( ) or Repair (�an Individual Sewage Disposal
Sys at:
..............VZ0. ..- • -•-• s -•----....--------------......................•-••••......•----•
_ Location Address -••-•or Lot No.
................................
...............
........... ... ..............._
Owner Address
......................................................... ---••-------•...._------.................•--.....•---•-•-•---------...............................
Installer Address
Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms................................ .Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons.......--------------------- Showers — Cafeteria
Q' Other fixtures ..................................
W Design Flow............................................gallons per person per day. Total daily flow..--..................._....................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width...---.-.-.----. Diameter................ Depth_.............
x 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 box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
aj Test Pit No. 1----------------minutes per inch Depth of Test Pit------.............. Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit.. ............... Depth to ground water...-------------.----.-.
------.
0 Description of Soil........".'
V ...--•------...-•-••-----------------•-....----•----•-•------------•-------••-•-----•••-••--------••---------------•--------------•-•----------•----- --
W ------------------------------------------------------------------------------------------PP...----------�---- - - - .-------- ------ . . --- -----
x -
UNature of Re irs or AlteXt'��,Answer when a livable... ....... . .. .. .......... ...: .. ...•......... ----•---. ----�f--- a --------------------------------•------.....------
Agreemen
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the-provisions of TTTIL y g g p y
_ 5 of the State Sanitary Code— The undersigned further agrees not to lace the system in
operation until a Certificate of Compliance has been ' d by the boar of health.
Sign ..-- - --- -- ----------------•- ••------------------••••......----•----.---- D
Date
Application Approved By.......... = .'IIJ04_ -•.•-•-•--••--•---- ---•-----
- Date
Application Disapproved for,the following reasons--------------------•---- ------............_.......-----...................-----........... a.t.•----......_...
c Date
PermitNo......................................................... Issued...... ...... :::- ---•------------
Date
,f
r
No.*.........a all... Fps `..............::...
THE COMMONWEALTH OF MASSACHUSETTS
f
„. BOARD OF HEALTH
1 •
........ - 4m- - _ ....-..-OF.........
1
Applira#ion for Bh4p aaal Witrks Tnnitrur#inn ramit
Application is hereby made for a Permit to Construct ( ) or Repair 4�1<an Individual Sewage Disposal
System at:
Al....::�.... L ti N
t ..............................................__-_..........................................
- oca on .Address or Lot o.
....................................................... -__
• ^
Owner Address
P44*4 a
----•------------ .............................................. .....-•---------•---•---._......_.._........__.....--....._.__....------------•---•-........•.....
Installer Address
UType of Building x t Size Lot............................Sq. feet
Dwelling—No. ofr Bedrooms............................................Expansion-Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons__.............................. Showers ( ) — Cafeteria ( )
d I Other fixtures -------------•-•••----•---•--------••-•-----
W Design Flow.............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity;...........gallons Length................ Width----------------- Diameter................ Depth................
x 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 box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
a
Test Pit No. 1________________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........................
- --------
D Description of Soil_______" __V.-__ __ _
,. .
V Nature of Re (airs or Alte at ns Answer when applicable.---._- Q' �4f ( " rez�'
, /
...............................................
The undersigned agrees to install the 'aforedescribed Individual Sewage Disposal System,in accordance with >J
the provisions of l!1T/'1�^ •�
TTL 5 of the State Sanitary Code—The undersigned further agrees not to place the sy f(!M' in
operation until a Certificate of Compliance has been • d by the boar of health.
Signs ..
v Date
Application Approved By--.... --.=--- •- - -L4-44-,, t:_ r Date
Application Disapproved for the following reasons:....................... _______________..............................................
-------•-----....._-----
•---------------•---...__...-----....---....-•----------•----•----•-----------•--•------.._..-----------•--------------------.-.-=--------------------••------=•-----•---_....--'----•--•-•-••--••-------
Date
Permit No. ................... d v�,_�„�:,. d
--•- Issued..... 1-- ,
e %tr"
• - ------•-----•......
_. Date
-THE COMMONWEALTH OF MASSACHUSETTS
BOARD O HEALTH
..........OF......... : ..... ,/�js°` ....................I............_.........
(grrtifirFatr of TnrnapliFanr
THI TO ERTIFY, That the Individual Sewage Disposal System constructs . ( .)..,or,Repairedd`
K_r
by........ --• . ..... ........... .................................... --
.. _ ..
has been installed i ccordance with the provisions of i` 5 of.The State Sanitary Coe as described in the
application for.Disposal Works Construction Permit N ::__A_tr/................. dated..... __"_ ...............
THE •ISSUANCE Off-THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
r DATE__..:_.....� '-.� ............................. Inspector________ _______
THE COMMONWEALTH OF MASSACHUSETTS
BOARD HEA T
t ' ............_OF... . . .....
--- _•....I......................... �,,.
No......................... FEE.'J..f. ........
x
inaa1 n2kh %nn1drailan rrntt
Permision i hereby grants •-- --- -• --•--- -•---•• •--•-•--•--------• ---•..... ... ...... .... . .......................
to Con tr t or air.' an Individual Sewa �os Sy e
Stree� _____ - -
at No. 4 ..,.----- --
as shown on the app 4cation for Disposal Works Construction Pe u No.. _a.__---_-__. Dated. "` r !"..----
..... • -
Board of Health
DATE------ •---------
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
L O VT ION ` D S E W A G E PERMIT
VILLAGE
s.
ce � l� Yv� ,� � �
I N S T A LLER'S NAME i ADDRESS
I UILDER ON OWN ER
Ivc11 -P � �
DATE PERMIT ISSUED �' _ 12.
.-
� ,�- -
DATE COMPLIANCE ISSUED
PaYc
i
31
f9
a
0
SF
47'
No.............� - _. ra "� v S� Fxs.... 1�..............
....
e THE COMMONWEALTH OF MASSACHUSETTS
A �r '
Cy j " BOAR® Off` HEALTH
. �Z , ..... . . ...�' ...o� ( ��
d
_p r lir Tian i= jig sal larks Cn.�a�s�r�r�irrn erutit
�A Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
stem at:
V) (* ° /,o T s'S'
4.............._...... f.4...........••....-•---- •-••-----Y---------................ .....------------. ---- ----
O L ation-Address -or Lot No.
G�/.�(L. /�.... ARA�!C ............. CENT !//L.6 .............................................
Owner Address
(1� W ���� •C u� 9 C..........
Installer Address
Type of Building Size Lot_. } __7_. Sq. feet
�— Dwelling No. of Bedrooms............................................Expansion Attic W-0) Garbage Grinder (lid)
p, ctp Other—Type of Building No. of persons......r ................. Showers — Cafeteria No
d7 U Other fixtures .......................... .
2�` Design Flow...........I.......`. _,5 ............gallons per person per day. Total daily flow......... Sa.......................gallons.
WSeptic Tank—Liquid capacity!��'._gallons Length................ Width................ Diameter_.-_____-____-_- Depth................
x i
Dsposal Trench—No. .................... Width_.................. Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No.--__-_-___--___-_- Diameter.................... Depth below inlet..._. __.... .._. Total leaching arr����__..____....._sq. ft.
tZ® Other Distribution box ( ) Dosing tank ( ) "Z0� ;W �2 j 7--
Z S� Percolation Test Results Performed b /4���t......v .N t_S___________________ Date......J,,l � / ..
Y
(L Test Pit No. 1__ .--__minutes per inch Depth of Test Pit------ Z...... Depth to ground water......
rZ Test Pit No. 2•...............minutesper inch Depth of Test Pit-_-./-Z_ .._.. Depth to ground water........................
�J
O Des_9ption of Soil-•--------------Q ` ... . •-•--.-::•�-�� . --- ----- ----------- -�'�-�
f --•---------------------------•-------
W ---------------------------------------------------------------------------------------------------------------------------------------
U Nature of Repairs or Alterations—Answer when applicable._----•.........................................................................................
•--------------------------------------- --------------•------•=----------------------•---------------------------------------------------------------------------------------------- --------
Agreement:
(® 'i' The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TI'I U 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
LU operation until a Certificate of Compliance has been is d by the board he th.
(!1
de
i� `/�� _Date
t/� Application Approved By........ r-•- ---- - ----- ----------• -.l,��!1- - �------------•-- ---�'-`S--'--��---••-- �
i41 W Date
•� P 0 Application Disapproved for the following reasons---------------------------------------------------------------------------------------------------------------Li p OD
•---------------------•---------------.-�-------------------------------------------------------------------------------------Date--------------
• Date `
_.:V .1
n;� 7 Permit No.•••••••••••-•------------------------•---•-•----•-----.. Issued-.--------------... e-••--••-•-••-•-•------••.......
. a_j co
fir•. / �1 .,�. � � -
Firm
-• :. ,
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....................... �.,
R. -.Appliratiou for Bt pos ai Works Tons union thrmit
Apple ation is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewtige Disposal
System at
.... } .. ......y........ .........•_______.._.__. ....... _........_.... ............... ........... ..... ..... .... ....,. `.... ... ....
R1�I ocon-Adds J w .: or Lot No.
h' 6 W ............................ . ......................f.. .....................................k Address
�� nPr,A'e�... > t
.._...-
Cam+ N��jr ^Installer Address
�y
S feet
U� Type of Bu> ding � ,� �. Size. Lot----- ------------------- q•
a _ Dwelling� ,lQo. of Bedrooms..............---. ---- �-.___Expansion Attic (, )�" Garbage Grinder ( )
Other=Type}of Building .........................^..'No. of persons.....__.�................ Showers ( �'— Cafeteria ( )
Otherfixtures • -----------= •------•-•--•--•-•--•---•--•--------------------------•---
W ' -Design Flow--":....._.......! -t�� .....-_.gallons per person per day. Total daily flow............................................gallons.
W0 Septic,Tank—Liquid capacity ....gallons. Length....__ _. Width ............. Diameter__._.....__..._. Depth.._.._...__.._..
x Disposal4Trench-No. ----- 2 Width.................... Total Length:..:..:......_.... Total leaching area................... ft.
ISeepage Pit No..._...�.......... Diameter.................... Depth below 'inlet........ ........ Total leaching area..................sq. ft.
Other,.-Distribution box� )„y Dosing taglc ) .. -�
e , = eq e
ercolation Test Results Performed by.................... ........................... ---. --. - Date........
�a Test Pit No 1 .¢� minutes per inch: Depth of Test Pit----------_......... Depth to ground water Sl �`
a Test Pit No. 2�".__. nunutes per inch Depth of Test Pit y Depth to ground water.
.__...... ............. __... -1- -. ..............
.. 4
O — Description of Soil...... /
w >L ------- __•.`•--------------------------------------------------------------- ----
U Nature of Repairs'or Alterat-ions .Answer when applicable-_----------------
.............................................................................
Agreement �{ �t
he~,undersigned'agreesYto install the aforedeseribed Individual,Sewage`Disposal System in accordance with
he provsions,of TI: 5 of the State Sanitary Code— The undersigned fui ther a ees no o place the-system~t.,
4operation until a`Certificate of Complizance has been,hod by the-,boar of h . h*
1 Signed .... ... -•--- ----- ---••-•..-•-•-.._...
AV� w
,Ctl
`'� ,. � � � Date
�AppItc tion ApproveN.l ya;A /..44 .. t D
te
v."" Application Disapproved,for)the following reasons:................
....:.--• 'A t r
Date
Permit No...... ........ t........---------- , Issued..................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
w
r 9
BOARD ,OE-:.HEALTH
OF..... ...... s ..............
'f" ittnrr
f�rr�� �rtt#r of (hunt �
iL
THIS ISrMO�, TIFY at the Individual Sewage Disposal System constructed or Repaired ( )
by * ----- -• -• -- ......................................_.. ..----• .............••--- •--- �� ,--- ----------
f ,��
I stall ,,� �'�,,,,,.. '"�C"• �
at.._... - -ems- .. - - •-� �.� ,, - --•---- -- -------•---•-- _
has been ins led �cordance with the provisions of T L jf The Sanitary Code as described in the
application for,, isposal Works Construction Permit No.. �......__._ : �..__...._. dated_.. S` -. . .................
THE ISSUANCE-OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. y
DATE .. Inspector' __ A ..............................
a. . . - ,+RX..�i;a+SFifl.,au .Fc„ti.:•:�dw+'.-+cer..�wr.;s.+>>++wvJrS..a�rncga:+ ±sv�-.- r a ...,..
•,,G� 7d.�=�s+.,..,a..xr�_ T .._d.,. .,:: ,a �.�+�r _.w���3n�'ar+ a...., I,r. '�":. R�� ,...�.,.. ,.+.rr�Lvm��i,
THE COMMONWEALTH OF MASSACHUSETTS
_BOARD HEALTH
/.2 .....,,�'�........OF........ .,,
S
... 9 ...... -,..
No..... .`....... FEE: ((S►... - ,
Permission is hereby granted4M ....................... ......... .n.._._. ........ ... :.
to Construct ( . or �10'
ir"( ) an Individ wa e Dispos System't
at No *-• Qt 4 �«' aS .....
t
f
F.
:..
Str et OA
Dated '" �� ..as shown on the application for Disposal Works,Construction P it i.11 7 `----------------
'...... u+ '.._a.__ '►�`-•-...._.. ._. ..7 ................................»
, / �� y4 Board of He¢
DATE._ . --------------•--• -- V
key
FOR MS.12'55 HOBB§ & WARREN ZINC., PUBLISHERS
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A
TOP FNDN. AT EL. 23.5' SYSTEM STEM PROFILE TEST HOLE , LOGS
ACCESS COVER TO WITHIN 6" OF FIN. GRADE (NOT TO SCALE)
ACCESS COVER (WATERTIGHT) TO
ENGINEER: LISA LYONS, RS
MINIMUM .75' OF COVER OVER PRECAST WITHIN 6" OF FIN. GRADE 2% SLOPE REQUIRED OVER SYSTEM 22 0' SAM WHITE, RS
WITNESS:
EL. 276 RUN PIPE LEVEL 2" DOUBLE WASHED PEASTON DATE: 8/28/03
FOR FIRST 2'
3'Q MAX. < 2 MIN/INCH
EXISTING
1 PERC. RATE
Fr
5 0 _GALLON sEPrlc 19.3'f* 19.0
oo Locus
P7 10560CLA5STANK H- TO GAS SOILS
'' (RE-USE) BAFFLE 18.50 0 00 c a
18.67' 018.17
Fo
x RUN
El Cl 0 E 1 ED Ci ED CD
6" CRUSHED STONE OR MECHANICAL 80 ,
oaaa El Doom 4 ELEV.
COMPACTION. (15.221 [2]) MIN oQ�o 2 E] CI C7 Cl 0 0 tD o00 16.17' O„ 22.1' ��`� SEl+ �9
DEPTHof Flow = 4 ( MiN SLOPE)
TSTEE SIZES: %( t SLOPE) 3/4" TO 1 1/2" DOUBLE WASHED STONE �`ti
T
INLET DEPTH = 10' FILL
OUTLET DEPTH 14. 25"
LOCATION . MAP NTS
O/E
FOUNDATION LEACHING EXIST. SEPTIC TANK 22' D' BOX 11' MS
FACILITY 5.07 ASSESSORS MAP 227 PARCEL 135
*THE INSTALLER .SHALL VERIFY THE -_
30" 2.5Y 6/1
LOCATIONS OF ALL UTILITIES AND ALL B
BUILDING PRIOR TO S INSTALLING LANY PORTION OF
SEPTIC SYSTEM LS
11.1' 10YR 5/6
59 17.2' I
C
OF PERC
EOG
M/Cs
10YR 6/6
132"
- NO WATER ENCOUNTERED
_ A� l NOTES:
T�
SEPTIC DESIGN: (GARBAGE DISPOSER Is NOT ALLOWED _) 1 . DATUM IS APPROX. NGVD
DESIGN O,A/ 5 !li ^..1AAC -
. . USE A 550 GPD DESIGN FLOW
Gs pC� LOT 35 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT.
1 16 849t SQ. FT. ►- ; \ SF?TIC TANK: 550 GPD - 4. DESIGN LOADING FOR ALL PRECAST UNITS TO BE AASHO H- 10
i 12 _ (�2 ) _ 1 100 5. PIPE JOINTS TO BE MADE WATERTIGHT.
1 - Uc,E q 1500 GALLON SEPTIC TANK {RE-USE EXIST} 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH MASS.
LEACHING: ° ENVIRONMENTAL CODE TITLE V.
1 OAK QP \\ SIDES: PERIMETER = 121 x 2 (.74) -
179 GPD 7. THIS PLAN IS FOR PROPOSED SEPTIC SYSTEM ONLY AND IS NOT
TO BE USED FOR ANY OTHER PURPOSE.
PAVED \ BOTTOM: AREA = 540 SF x .74 = 399 GPD 8, PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC.
DRIVE \
-!_\ TOTAL: 781 S.F. 578 GPD 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED WITHOUT
INSPECTION BY BOARD OF HEALTH AND PERMISSION OBTAINED
22 / \ USE (5) 500 GAL. LEACHING CHAMBERS (ACME OR FROM BOARD OF HEALTH.
\ iEQUAL) IN CONFIGURATION SHOWN (SEE DETAIL) 10. PUMP & REMOVE EXISTING LEACH PITS
cl ry ( 7d. 0 KUl
\
\ \
\ \
6" 1.RE \`
EXISTING DWELLING LEGEND TITLE S SITE PLAN
� TF = 23.5' GRAVEL DRIVE/PA ING \
PROPOSED SPOT ELEVATION OF
\ 420 ELLIOTT ROAD
100x0 EXISTING SPOT ELEVATION
c� Q L > IN THE TOWN OF:
do 1 ( 100
O
o`r / PROPOSED CONTOUR
--
,,� , C ELATE RVI LLE) BARN STABLE
BENCH MARK — CORNER 9ti
100 EXISTING CONTOUR
i PREPARED FOR:
OF CONC. BULKHEAD �A / % ��2 TONY ELIO
ELEVATION = 23.1 GPD ,
tit co 20 0 20 40 60
CAT 10 PIN � ,,,.
y / -�-CA7 BOARD OF HEALTH
s
g \ / EXIST. 1500 GAL. 1 „ = 20 AUGUST 30 2003
J
�9- `i, ��, j o O SEPTIC TANK (RE-USE) aP Q E DATE MA SCALE: DATE:
,0 `L
\ � off 508-362-4541
`Z \ 10" OAK fox 508 362-9880
Of Of MAs�
2 \ �� `' ARNE 9^y
5' REMOVAL OF UNSUITABLE SOIL REQUIRED dowr7 cape engineerrng, Inc, ��`� gRNEfI H. �
AROUND PERIMETER OF LEACHING FACILITY, aA OJALA _I
LEACH FIELD DETAIL DOWN TO SUITABLE SOIL LAYER (DOWN TO C CIVIL ENGINEERS C1V1tq- No.26W
1" 20' �9 LAYER — SEE TEST HOLE LOG). REPLACE WITH ,o NO. q
� CLEAN MED. SAND.
LAND SURVEYORS
3--2 1 7 y
939 main st. armo uth ma 02675 7 L19 e 3
AH. OJALA, D,E., P.L.S. DATE
�g �
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