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HomeMy WebLinkAbout0029 EMERSON WAY - Health 29 EMERSON WAY, CENTERVILLE A= a i i �///»PQ� vsc UPC 12534 ' No.2�153_R �, s� HASTINGS, MN wili Y. 4 iDATE:. 9i 1,2'/91IRE C EZ OLI 29 Emerson Way HEALTH DEPT. Mass . 02601 WMI OF BARNSTABLE i On the above date, I Inspected the septic system at the above address. This system consists of the following: 1 . 1-1000 gallon septic tank. ,,� • 2. 1-Distribution box 3 . 2-Flow Diffussors 81x4l Side to side. Packed in 21 of stone . 121x121 Eased On my Ir►8t>&ct1on, I certify the foilowl g coriditlo s: 1 . This is a title/-five septic system. •� ) 78• Code• 2. The septic system is in proper working order.. at the present time . - 3.. No repairs are needed at the present time. SIGNATUR!-: ------------ j . '• Y: "._ c _ ,ber & Son, 'Inc . _—Centervill,e , Mass__0.2632 Phone:___548iZ7,5�3338------- THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY ' E N P. h�ACOMI3ER & SON, INC. Tandcs-Cos4pooIa Leachfleids Pumpod & Installed Town Stwer Connections P.0. Box 66' Centerville, MA 02632-0066 775-3338 775-6412 f 7' (_'� mmonweatth of Massachusetts .;ecutIve Office of Environmental Affairs :s apartment, ®f anmental Protection Cox Trudy . .=-,. ,, Argue Paul Celiucci avid S.Struhs LL oa,emw comrjulorwr SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION PropertyAddresa: Herbert Sunderman AddressofOwner. 29 Emerson Way Date of Inspection: 9/12/9 6 (if different) Centerville ,Ma s s Name of Inspector. Joseph P.Macomber Jr. 4.w 02632 Company Name;Address and Telephone Number. J.P.Macomber & Son Inc. Box 66 Centerville ,Mass . 02632 508-775-3338 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes _ Conditionally Passes 1, r 4Oiar Evaluation By the Local Approving Authority Inspector's Signat "„ �' t Date: / ✓�7— The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report.to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner ru:d copies sent to the buyer, it applicable and the approving authority. INSPECTION SUMhLkRY: Check A, B, C, or D: A) SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. , B) SYSTEM CONDITIONALLY PASSES: ivU One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. Indicate yes, no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not) A,O The septic tank is metal,cra^.ked,structurally unsound,shows substantial inf:ltratiob or exMtration,•or tank failure is imminent. Tha system will pass inspection if the existing septic tank is replaced with a ponforming septic tank as approved J by the Board of Health. (revised 11/03/95) 1 One Winter Street a Boston,Massachusetts 02108 a FAX(617)556-1049 a Telephone(617)292-SSW Printed on Recycled Paper SUBSURFACE SEWAG)C DISPOSAL SYSTEM INSPECTION FORM PART A'. CERTIFICATION(continued) . .. ;• ,-..::n - ion Way Centerville,Mass . 02632 Sunderman Date of Inap zi<: >9 12 96 Bl SYSTEM CONDITIONALLY PASSES(continued) �Q Sewage backup or breakout or hob static water level observed in the distribution box is duo to broken or obstructed pipe(s) or duo to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health: broken pipes)are replaced ` obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board..of Health): broken pipe(i)ara replaced obstruction*'removed Cl FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: ._A O Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the r;-!t,�, !,T:tv Qnd 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 60 feet of a.surface water A;0 Crj2.>.cl or privy is within 60 feet of a bordering vegetated wetland or a salt marsh. Z) SYSTEM WILL PAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER.IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND n 7nc zy: .s::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. �Q The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 60 feet of a private water supply wall. The system has a septic. and roll absorption system'and is less than 100 feet but 60 feet or.mors from a private water supply well,unless a'well water analysis for coliform bacteria and volatile organic compounds indicates that the well is hen from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 6 ppm. 3) OTHE4t (revised 11/03/95) 2 t � SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(oontinued) Prop rtyhlc:v..•± ;=9 ilmierson Way Centerville,Mass . 02632 , Owner. Herbert Sunderman Date of Inspection: 9/12/9 6 DI SYSTEM FAILS: , AZ 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. �IJI> Discharge or ponding of effluent to the surface of"ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than W day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped A? :Z-.v -rt?t of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. A.uy portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. if Any portion of a cesspool or privy is within a Zone I of a public well. po Any portion of a cesspool or privy is within 60 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 60 feet from a private water supply well with no r.c.z^t.:ls1a—ntzr quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for cx�lii� cu ria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. El LARGE SYSTENa rATL:9: The Lipp ly to large systems in addition to the criteria above: The *._ * lity with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 1 tb 3 Lyst=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 wvll) The owner or operator oi-any such system sliall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 6.00 and 6.00. Please consult the local regional oMce of the Department for thither information.. (revised.11/03/95) 3 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST PropertyAddress:29 Emerson Way Centerville,Mass . 02632 Owner. Herbert Sunderman Date of InspeotIon9/12/9 6 • Check if the following have been done: ,Pumping information was requested of the owner,,yocaupant,and Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. -i� A built plans have been obtained and examined. Note if they are not available with N/A ZThe 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. j/All system components,eluding the Soil Absorption System, have been located on the site. e septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid,depth of sludge,depth of scum. , The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. ZThe facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub. Surface Disposal System. (revised 11/03/95) 4 �J SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Prop*rty.W 29 Emerson Way Centerville,Mass . 02632 Owner: Herbert Sunderman Date of Inspouliuu:9/1 2/96 FLOW CONDITIONS RE9IDENTIAI.: Design 110w: �nllonst� l�s� Number of bedroom&:-jV- W/ 1 C Number of current residents: (- Garbage grinder(yw or no):;� Laundry connected to system(yes or no):LY�7 Seasonal use (yes or no):4Z f/ Water meter readings, if available: 5 Last date of occupancy: 7� COMM ERCIAL/INDUSTRIAL Type of establishment: AA Design Aow:AA-gallons/day Grease trap present: (yea or no)-MA Industrial Waste Holding Tank present: (yes or no)l)-& Non•saaitary wasto dischaxor&d W the Title 5 system: (yes or no)-hA Water meter reading, if available:_ Last date of occupancy: OTHER: (Describe)�h Last date of occupancy:_jI GENERAL INFORMATION PUhIPIN( ?I}: ^nr r of��y]('�.�,nnation:�.°�(� of ins ion: (yes or no)" If yes, volume pumped: ons Ranson for pumping: TYPE 0 SYSTE?d Septic tank/distributlon boz/soil absorption system -- - Sln,gia ac�pcol _��/ Over-now cu:.rpool Pricy Shred system (yes or no) (if yes, attach previous inspection records, if any) Othar (eyplr in)� AP ROXDLV!' AGE of aii components, date in-Balled (if known) and source of information: Sewage odors detoctad when arriving at the site: (yes or no) (revised 11/03/95) 6 f, 'CL• S ;1'i:vi DISYUSAL SYSTEM INSPECTION FORM PART C. S'r'ST :.t ; :i( 1 IAATION (continued) Property Address: 29 Emerson Way Centerville,Mass . 02632 Owner: Herbert Sunderman Date of Inspection: 9/1 2/96 SEPTIC TANK:?,a400 (locate on site plan) a Depth below grade:,,6-- Material of construction:j concrete _metal _FRP _o0hef(expl3in) � r Dimensions: " 1 � ----—.- Sludge depth-._ _ r Distance from top of sludge to bottom of outlet tee or baiil;::�.._ Scum thickness: 74Wk �uW✓� Distance.from top of Scum to top of outlet tee or bafile:� Distance from bottom of scum to bottom of outlet tee or bafiie._ Comments: (recommendation for pumping, condition of inlet and outlet tees or baffle depth of liquid level in relation to outlet invert, structural '.rity, evidence of leakage, etc.) Pump 'are, _ ia�olaze_;,Liquid level at_�t1et—i t' ~ .n-k--i-s..: .s true turally._. _SQund; Ther.t.ank does not_�h�w__any s�g of lea zage. No _...repairs are npprlejj at the irpsant time- GREASE TRAP. /vd4Je. (locate on site pian) Depth belo.s' grade:,4)'ff Material of eonstrurticn.Ax:oncreee _metal _FRP ___ou,e!(explain) W. Distance from top ul scun, lC` i (cC UalliC:,:� Distance from bottom of AIR (recommendation(recommendation for pufPgl^ of inlet and UJhet l eS ur Uafllcs, depth of liquid le,,cl In relation to ou(!.. oveo, S(n.lr'rl,ir',;I I nlegl�ty, evli'er1 C:: :;I _ . - s.:..--..�.�•-- --- _! (revised 8/15/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) PropertyAddroaa: 29 Emerson Way Centerville ,Mass . Owner. Herbert Sunderman Date of Inspection: 9/T 2/9 6 TIGHT OR HOLDING TANK, (locate on site plan) • Depth below grade: ti-lr Material of construction:Q1 ncrete_metal_FRP—other(explain) A&f Dimensions: A14 Capacity: f)A gallons Design flow: ons/day Alarm level: Comments: (condition o inlet tee,condition of alarm and float switches, etc.) lilt) DISTRIBUTION BOX: l� (locate on site plan) Depth of liquid level above outlet invert: Comments: (no if level and b ion is equal, evidence of solids carryover,evidence of leakage into or out of box,etc. (al is eve' ;One outlet bein used: No evidence of solids carry over; Nn Pv; c3PnnP of leakage in or out of the box. No repairs needed a_ ___ PUMP CHAMBER:_&)At (locate on site plan) Pumps in working order:(yes or no) A/¢ Comments: (note conditi''oon of pump chamber, condition of pumps and appurtenances, etc.) (revised 11/03/95) 7 -.;"U-FACE SEWAGE DISPOSAL SYSTEM INSPECTION PO 4.f PART C SYSTEM INFORMATION (ooutlnuod) 29 Emerson Way Centerville,Mass . Q, , . ' Owner. Herbert Sunserman Date of wp"a4w 9 12 96 SOIL ABSORPTION SYSTEM(SAS) : (locate as site plan,if possible;excavation sot required,but may be approximated by uon•intrusive methods) If not determined to be present,explain Type: p leaching pits,number leaching chambers,number. leaching galleries,number. leaching trenchos,number,length: leaching fields,number,dimensions- overflow cesspool,number: Comments:(note condition of soil,signs of hydraulic failure level of ponding,condition of vegetation,etc.) See Page 9A; No signs of hydraulic failure;No signs of ponding; All vegetation is normal; No repairs needed at the _mre4ent time. CESSPOOLS: ,!/ (locate on site plan) Number and configuration: Il R Depth-top of liquid to inlet invert: g//St Depth of solids layer: d/A Depth of scum layer. Dimensions of cosspool: o Materials of conwtruction: AA Indication of;rouadwatar: 9J in low(oaupool must be pumped as part of inspection) Comments:( ca condition f soil,s' of hydraulic failure,level of pondiag,condition of.vegetation,etc.) PRIVYs d20V6 (locate on site plau) Materials of construction: Dimensions: '41 14 Depth of solids: Co 'tr(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,-etc.) .o.�sir (revised 11/03/95)• 8 7. E SEWAGE: DIBPOBAL SYBTEM IN8PECTION ,NORH N; aU13aURAC • PART'.B SYSTEM INFORMATION continued SKETCH OF SEWAGE L_SPOSAL SYSTEM: include ties to at least two .permanent references landmarks, or benchmarks locate all wells within; 1001 Centerwille .Osterville Marstons Mills Water •Company , 428=`6691 DEPTH TO Mr." depth- to groundwaer� m.4thyod of. determination or al2pr6ximati on: r ee Page VA SECTION - SEWAGE" c J� _v O -SEPTIC TANK - -••D"•BOX- -LEACH-TRENCH TOE Oc cON 24� IMSLI _ 2..ASKOF •TC N •w� ED STONE — _ 2!) / LA jci IN. foul. IN. . 2�•S3 21.39 ELEV. ELEV ELEV ELEV. / O•\yY 2 lli ELEV. ELEV. 1 / / •Z\ VF21FY HIGH WATE2- 'i �4? f ELEJ. Pfclo Fe To l cGIT NIAJ r . of...,l..• I / / W;'�4,0 GO N ST�'JGTIOiJ 5.� WASHED STONE �'f e,(ham (I 2 TEST HOLE LOG t4} -- �^ a� 4b" ELc/. obna 14 -1 /1 (` L.+ 55) TEST ev R.FA1RB PN AUKp-e. O G1FFopG B-N o. w..ta;� \q PZ bQ j�,o.T' P d TEST DATE It 121 1'32 WITNESS DESIGN _ E d_ BEDROOM HOUSE W e��. * l For} T.H.. I T.H.•2 \0 — ��P fT+d.E+24.0- I IS't \q Y.�-�+- ELEV. — -�.�- ELEV. PERC RATE MIWIN ' Aj Z^`I 24G lI�,m; zo.o DI$iOSER t D15703ER �Z•+ dncKi\ O ♦.•r-1 .— . 18� --el.'23.1 f,ne. 24R GI-=IEi•o FLOW RATE 22o IGALJDAV I 220 L O+ 5-7 SEPTICTANR ZZox IL9. 3 48F el.-IG-o REO•D SEPTIC TANK SIZE 000 ynd .y - �- 64 e1=14.3 72 e► 14•o� LEACH FACILITYcw. Ra w.ter SIDE WALL 12•"4■•9G•4fo.1(2.S) . 1\5.2S.G/D. i LOT 5 G— —N 1 sA..d 9G BOTTOM 12.'* 12' 144 s.f.1 I.o) 144 G/D. TOTAL 19o"1 S"f 2S9.z5 GiC 'U 1RA4c USE: FL• owD1FF USoR LEACHING 144 .A. l2. LoN x cs WATER ENCOUNTERED G 1�1 wIOE \ NOTES: (UNLESS OTHERWISE NOTED( ICI NN C 1N OF F• / `tA 1.OA'i t;M IMSU TAKEN FROM ....----OUAORANO\E NAE �E.` J� 1,ML!-•.CIEAL wwrEa__S _"—___"-__+AV AILAeLE mot/!` p?4 ARNE a.wE,.:•-ITCH:o••EER Fool 1/G' 9 �> •.OC:•+':1 LOADING FOR ALL ERE{AST UNITS:AASNO- 10 ..� z AJA H. G� : DJALA __ 3.MI^ +OUNO COVER OVERALL SEWAGE FACILITIES:111 ET. CIVQIu :I .3 .26Y1a DISTANCE AS CERTIFIED \� e.OG 6,qr.x `ITS SIALI RE!R ADE WATER TIGHT N �'� ).CO--i.••UCT:ON DETAILS TO BE ACCORDANCE WIT(COMM.OF MASS. No..3D792 STA•;ENVIRONMENTALCOOE TITLE 5 SI ° SITE PLAN ETA RED.DROi[SSIONAL ENGINEER .--- �S j_r S Py I L L a MASS. _ REF LOT 5 L.C-P 24614 E down cape EREPAREDFOR: HERBER.T SUW1'-EjRRgAti CIVIL ENGINEERS ------------ BOARD OF NEALTN LAND SURVEYORS �•��� REG.LAND SUAVEVOR � CONTOURS IE SO-SEDI-n-•)-n-"'O-. .-ROVED .._ :JATE A Vrj (1 P'-AMA r•YA SCALE 3� DATF #84-O G. - w � b V) IOU T _COMMONWEALTH OF, .MASSACHUSETTS_.: DEPARTMENT OF ENVIRONMENTAL PROTECTION BE IT KNOWN THAT " Joseph P. Macomber, Jr. " Has satisfied the Department's qualifications as required and is hereby - authorized to use the title < < CERTIFIED TITLE 5 SYSTEM INSPECTOR as provided in 310 CMR 15.340 and Section 13 of Chapter 21A of the General Laws. Issued by The Department of Environmental Protection. June 8, 1995 Acting Director of the ' ' ion of Water Pollution Control 4:. .-n-1r.r. :c...—.__.�._•_._r—.=--r..—.rr.:-:—•.r_rr:.._.........r...-c:r.—'=-re-:r.._. ...._.__.. .... .. ._.. TOWN OF Barnstable BOAl2D OF 11EALTII 1 Sl1USlIRFACF SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION '.._�. F..._;.;_.r..._....__,;r-...-.—:.r..—:•n:—:—s.^-:.-...-----...—:.— ...... -r-..:..st.—r._--.-rscsr._:-«—r.•r�-sr.�.r._rrssxsat-r-r.•tvcrrrrs-rrrrrrrr..—rrr r. -t. . -TYPE OR PRINT CLEARLY- PROPERTY INSPECTED STREET ADDRESS 29 Emerson Way Centerville ,Mass . 02632 ASSESSORS MAP , BLOCK AND PARCEL # OWNER' s NAME Herbert Stinderman PART D - CE1?7'IFICA7'I0N -Y NAME OF INSPECTOR Joseph P.Macomber Jr. COMPANY NAME J.P.Macomber & Son' Inc. COMPANY ADDRESS Box 66., Centerville,Mass. 02632 Street Town or City State LIP COMPANY TELEPHONE ( ) - FAX 508 775_ 3338 508 790 - 1578 • ns CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate, and complete as- of the time of :inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one : XXXXXXXXXXSystem PASSED The inspection which I have conducted has not found any information which indicates that ,the system fails to adequately protect public health or the environment as defined in 310 CMR 15 . 303 , Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . Systew FAILED* The inspection which I have conducted has found that the system fails to protect the public health and the environment in accordance with Title 5 , 3.10 CMR 15 , 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . ZInspector Signature bate 9/13/96 One copy of this c tIfication must be provided to the OWNER, the BUYER ( Where applicable ) and the BOARD OF WEALTH. * It the inspection FAILED, the owner or"" 'Pierator shall upgrade ' the system within one year of the date of the inspection, unless allowed or required otherwise as provided in 310 CMR 15 . 305 . --- TOWN OF BARNSTABLE ;,so `� LOC:ATiCF `'® �.�'lt�"18.91 l/U/�Y SEWAGE # VUL ,AGE //' ASSESSOR'S MAP& LOT �g QA L p ��"' � S NAME&PHONE NO. i SEPTIC TANK CAPACITY AM r LEACHING FACIL=: (type) /" lL9 5 (size) NO.OF BEDROOMS �Z BUILDER OR OWNER PERMUDATE: q--Ig— _COMPLLANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility I 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 hj�g fibli Feet Furnished by A4 THE COMMONWEALTH OF MASSACHUSETTS ►/ /�� BOARD OF HEALTH �zy�� FW' ..........................................O F..................................................................................... Trtifiratr of Tnutlitlattrr TRI.S IS,TQ CERTIFY, That the Individual Sewage Disposal System constructed ( . ,or Repaired ( ) 1 ......--•-----•-----•---------------------------------------------------------------------- . Installer at-------- ... �"� has been installed in accordance with the pro si s of TI FF 5 of T tate Sanitary `C�d r' din the application for Disposal Works Constructio P rmit No._ _.L__- -� ------ dated---j- -.� ------- -----------•--------. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRII A GUARAN E THAT THE SYSTEM WILL IWKUI N SATISFACTORY. DATE.....:;. 2 ._.. Inspector. -- --WW�-- ------------------------------------------------------------------------------------J Y. No. .....�...... ..........................._ THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH .............. ...........O F...........................-_...-........ ......_....... Appliration for Ditipas t1 Works Tnnstrnrtinn frrmft Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System(at: ..---L:�.�`_ '�_...... -s`� -W -�---------- --•--••-•-•-.......•--•----...•-•-••••-----•-•----•---._...--••--••------•------------------------ '' a.±?-AA�dddress ...................•-------..............-- Lot No. N J eQ��'t �vrl zs[�Pp+nary eta�' ' ..... ...... p y Owner / Address y W f &J.....��i S. �Y It�W Installer Address UType of Building Size Lot.................... .....Sq. feet ., Dwelling—No. of Bedrooms................:...............•_----------Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building `!1`�do. f person s............ ......... Showers ( ) — Cafeteria ( ) Gip Foci p" Other fixtures ...' V W Design Flow............... .® gallons per person per day. Total daily flow..........2 -....................gallons. WSeptic.Tank—Liquid capacity Z!!Wgallons Length................ Width-•..-_-____-____ Diameter________-____- Depth................ x Disposal Trench—No...._.../Z...... Width..... .... ...... Total Length.................... Total leaching area... .�2-----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........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water------_................. (s, Test Pit No. 2................minutes per inch Depth of Test Pit-................... Depth to ground water._____-__-_____----_____ a' •-•-•---•----••-------------•••---•-••••-•-••••-•-•--•-•-•--•-•••••••-•--•----•-••--......--•--•............................................................. 0 Description of Soil........................................................................................................................................................................ W U ••••••••-•----•---•-•--....--•-••.........•••••••-•••••-•------•...........-••-•-••-•----------•---•••-•-•-••-••-•-•--•---•••--•-•-••---•-••-•-•--••-••-•-•--•-••••••-••-•------•-•••-•--•-••-----•----- W Z -----••••-••---------•-------•----••••••••-••---•---•-••-•-•---•-----••-•••••••••••--••••••------•-----•------••------•-•-••----...•--•-------------•••••••••--••••••--••--••......--•••............-•-- V Nature of Repairs or Alterations—Answer when applicable- Agreement The unde signed agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITI.% 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance s een 'ss ed b the oa of health. Signe td�ry ... - ...- • - - Application Approved By... ----- -----•---••••-•---•-•---••-••-•-•......--•-•................... :_7 ......dam Date Application Disapproved or t e following reasons----- ---------••----••-•---••...••-•-•----------------•-----•----••--•---•--•-•••--•-••--•--------•--•••--••--- •--------------------------------------------•-••-•-•--•••-•-••••••_.._....---••--•----•....-•-------••-.•-•--•••--••••---••••-•-••-•-•-••••-•-••••------------------•--••-•--•----------••••----•-•---- Date PermitNo......................................................... Issued....................................................... Date No.. t �' _ '1 FR$.............................. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ..........................................OF...............-.............. ....... Appliration for Diipnii al Works Tonstrnr#inn Upprmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at .......... ..... ..-�-'�............. -..'�"s�..............t`1,..........-•---... .................................................................................................. ��/ ation- ddress or Lot No. ..............• ......•--•-----•--. -----•--••-------•--•---•.....----------•---•-- ..........-•................................. - -.....--- Owner Address Installer Address Type of Building Size Lot----------------------------Sq. feet aDwelling—No. of Bedrooms............. ..........__..,_.........Expansion Attic ( ) Garbage Grinder ( ) 44 Other—Type of Building 6P+�Q� �✓arr�'�To f persons............ Showers ( ) — Cafeteria ( ) tiI Other fixtures ..-romok S"'o .k..Tv?...... •--•••-•-•-••-•••••--••----•-•------------•--••-•.............•----•......••--............-•-- wDesign Flow..............4r....................gallons per person per day. Total daily flow..........2,X:10....._.............._gallons. WSeptic, Tank—Liquid capiacit l!1VW.f gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No:........ ....... Width....L;4------- 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 ( ) 1-4 Percolation Test Results Performed by--•-•------•-•-------•••---•••---•-•---••----•--•••-•----•--••-••......•• Date........................................ 14 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........................ a ............................................................................................................................................................ 0 Description of Soil....................................................................................................................................................................... x 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 TITIL 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance as been is ivied y the oa of health. C� Sign 1 r t f wrz.. �f"7'ear ------ Application Approved By/�. •-•--•-•-------•-•--•-----......_ f Date.....Application Disapprovedfor te following reasons:....................... ..-------•----------•------------------•-------------------•-------------......-----------••--------------•-••-••••--••-----••-•--•-•••--•--••••-•----•---•-•--••-----••-•-----•••-•-•••--•-•-•--------- Date PermitNo......................................................... Issued..................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF.................................................................................... Tntifiratr of TuntpfiFanrr TS IS T CERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( ) by -••-- ..-- ................... .........••-----------•--.........•-•._...-•-------••-••-----•.......------•.._.._...•--•--•---------•------•-----.....-•----------•-•----------•------ Installer ,r has been installed in accordance with the provi ns of TI" F 5 of T State Sanitary Code`''a� kEETHAT din the application for Disposal Works Constructio _ rmit No.- `. -----••... dated f . THE ISSUAN E OF—THIS CERTIFICATE SHALT. NOT BE CONSTRUED A A GUARAN THE SYSTEM IYJLL 77. N SATISFACTORY. DATE..._.:. .. ------•........................•-----••--•-•-_. Inspector..-•-- ... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF.................................................................................... . N 0...................... FEE:f...... ........ nstrndion Wrmff Permissionis,hereby granted. . ...................... ---------------------------•---•-•---------•--..........---•-----..._.. -------------- fto Construct ( �;; r e ai ( Individual Sewa e Di p sal System at No.•-•---•••..�. �. -, .. -' 'er� ''� - ----- Street � a,4 shown on the a li ion for Disposal Works Constr1 Permit No ___ Dated.......................................... ........................... s 1 - ......................................................... DATE..�............................................... Board of Health•� FORM 1255 A. M. SULKIN, INC., BOSTON L0-tA" 10� / SEWAGE PERMIT NO. ol 75' VILLAGE + INSTALLER'S NAME i ADDRESS B U I L D E R OR OWNER C, DATE PERMIT ISSUED DATE COMPLIANCE ISSUED � ~ 14vras®� AA • ' i' a��dSlt�4 SECTION - SEWAGE`S; • O _ --SEPTIC TANK - - "D"BOX - -LEACH "TjeENC H TOP OFgQFON (MSL)a —11211 OF 118TO 42" WASHED.STONE ` ` ,LG) M ; OyJ IN 10©� OUT- IN• OUT+ IN-CG 22 2{.S� 2t.3q TTC TANK �!'� ELEV. £LEy. �' ELEV. ELEV. �{_ (Z' 2©.'-70 /ZO.153 - " ' 0 23 � "'" � �N�•'�.� ,� t ELEV. ELEV. \ISP-IFY HIGH WATaP ELEV/. PPIoR To BEGINNING �_ x � o f'1 C-0 ST F C--r 10 hJ �j.5 WASHED SOF TONE IN, ZOO TEST HOLE LOG 14t ELEV. observe 5S wtier Gar TEST BY�.FA1.g8A.Wkrp.e. Pop 61FFopt,�� B.H.O. ; TEST DATE (�12s�$0 WITNESS Z BEDROOM HOUSE cSW��� `porgy q -,— DESIGN �tld e 24.o- 1 ►5 T.H. 1 T.H. K 2 ELEV. ELEV. NO octm PERC RATE Z MIN./IN. )O rn 24•G l ZOO DISPOSER DISPOSER .� `2� ��cl�, ` O -Fine Z4 a .= •o 20 1 IS FLOW RATE 2 (GAL./DAY) 22d L O+ S-7 1 1 gravel l;ine SEPTIC TANIe, 2.2.0 x 0-5)= 30 (� s4 �$" el.= lCo•o R1_O'D SEPTIC TANK SIZE F, - °ars G4 �.=1a.3 �� Sand LEACH FACILITY clew 72 �M. e.i.=14.0 n,ed. Ww+e SIDE WALL 12''�4-�sC.9Co=4Go.112.S t - 1 \5.25 G/D. � /--L07 5G�— � ~N I sand 9� BOTTOM 12'x 12` = 1:44 Si-( I.o ) 144_ G/D. TOTAL 1 go.I s.JF. = ?.'S . G)D \ Ato a}er USE: FLOw> 1T=F:9 o LEACHING �5� -- \ 144� 12 t_otaG x 12 w►D�E � \ YES WATER ENCOUNTERED 'NOTES: (UNLESS OTHERWISE NOTED) A ��F �4S 1. DATUM (MSL).+. TAKEN FROM.H'k j .tN I:5......... �(N OF�\ ` _..QUADRANGLE MAP / 2.MUNICIPAL WATER.__-_IS AVAILABLE ;�� � p`� ARNE J�, / O 3.PIPE PITCH: 1/4"PER FOOT / ARNE H. G' `+C H. i 4. DESIGN LOADING FOR ALL PRE-CAST UNITS: AASHO- (10 -44 °�% OJALA a�, \� �� r VI ALA ..,4 r s� AFC DISTANCE AS CERTIFIED 5.MIN. GROUND COVER OVER ALL SEWAGE FACILITIES: 1) FT. - a CIVIL � � '3$13 6. PIPE JOINTS SHALL BE MADE WATER TIGHT •- 7.CONSTRUCTION DETAILS TO BE ACCORDANCE WITH COMM.OF MASS. No. 30792 y �40 SITE PLAN STATE ENVIRONMENTAL CODE TITLE 5 Q� �P ^ Rf4Q �� �,Q £ J`f\•V�ti,C) ESE RSa��.i Rp LOCUS: CeWTEP.\/lL!_"F.., MASS. REG.PRESSIONAL ENGINEER REF: L-OT 24614 E }down cope engineefing PREPARED FOR: y g CIVIL ENGINEERS _----------- BOARD OF HEALTH ^� 9" main SL LAND SURVEYORS REG.LAND SURVEYOR 3Q` CONTOURS ((EXISTING)------------- APPROVED GATE �sACNS`CRI3LEMA Y i/A SCALE } $4-Otero (PROPOSED)—0-0-0-0— DATE r