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Home My WebLink About0100 ENSIGN ROAD - Health 100 Ensign Road Centerville -. A= 147-060 J�QECYCIfp�o III O � y2 UPC 12543 No. 53LOR �`°oS,•COHS°�` HASTINGS, MN Y„ t Commonwealth of Massachusetts W Title 5 Official Inspection Form a� - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 100 Ensign Road Property Address William & Linda Burns Owner Owner's Name information is required for every Centerville MA 02563 4/2/10 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. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Carmen E Shay use the return Name of Inspector "W, CD key: ; Shay Environmental Services, Inc. as Company Name F ; 185 Ashumet Road IL 0 Company Address eturn Mashpee MA 02649 - City/Town State Zip Code- 508-539-7966 3080 Telephone Number License Number ;may CT- B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails �4. ❑ Needs Further Evaluation by the Local Approving Authority u E. ? 4/2/10 �-!"�,Y a Inspector' nature DateThe system inspector shall submit a co of this inspection report to the A ''o'sto` rity (Board Y p copy P p pP ., of Health or DEP) within 30 days of completing this inspection. If the system is a s ared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****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. 100 Ensign Road Centerville•03108 Title 5 Official Inspection Form:Subsurface Se' a Dis I S stem•Pa 1 ofl15 9 P 9 P Y f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 100 Ensign Road Property Address William & Linda Burns Owner Owner's Name information is required for every Centerville MA 02563 4/2/10 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 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: leach pit has No Liquid-1.5' stain line noted B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed 100 Ensign Road,Centerville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 100 Ensign Road Property Address + William & Linda Burns Owner Owner's Name information is required for every Centerville MA 02563 4/2/10 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 100 Ensign Road,Centerville•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 100 Ensign Road Property Address William & Linda Burns Owner Owner's Name information is required for every Centerville MA 02563 4/2/10 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the 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. 100 Ensign Road,Centerville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 100 Ensign Road Property Address William & Linda Burns Owner Owner's Name information is required for every Centerville MA 02563 4/2/10 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes. No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply I 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 2000gpd- 10,000gpd. ❑ ® 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. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 100 Ensign Road,Centerville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 100 Ensign Road Property Address William & Linda Burns Owner Owner's Name information is required for every Centerville MA 02563 4/2/10 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: 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? ® El available as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] 100 Ensign Road,Centerville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a 100 Ensign Road Property Address William & Linda Burns Owner Owner's Name information is required for every Centerville MA 02563 4/2/10 page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required) ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonaluse? ® Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(9Pd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): 100 Ensign Road,Centerville-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments , a 100 Ensign Road Property Address William & Linda Burns Owner Owner's Name information is required for every Centerville MA 02563 4/2/10 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Board of Health Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance 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: 1982 - BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No 100 Ensign Road,Centerville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 100 Ensign Road Property Address William & Linda Burns Owner Owner's Name information is required for every Centerville MA 02563 4/2/10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 2.5 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.): No evidence of leaks, plumbing properly vented Septic Tank (locate on site plan): Depth below grade: 1 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: 5x 5' x 8' - 1000 gallon Sludge depth: 2 Distance from top of sludge to bottom of outlet tee or baffle 18" Scum thickness 1" 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? Measured 100 Ensign Road,Centerville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 100 Ensign Road Property Address William & Linda Burns Owner Owner's Name information is required for every Centerville MA 02563 4/2/10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank in good condition, inlet baffle in good condition, outlet Tee in good condition. 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.): 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): 100 Ensign Road,Centerville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 100 Ensign Road Property Address William & Linda Burns Owner Owner's Name information is required for every Centerville MA 02563 4/2/10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: Capacity: gallons Design Flow. gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert D-Box Present 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.): one outlet to leach pit and in fair conditions. No evidence of solids carryover Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 100 Ensign Road,Centerville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 100 Ensign Road Property Address William & Linda Burns Owner Owner's Name information is required for every Centerville MA 02563 4/2/10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1-6'diam x 6' D ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): SAS fuctioning properly, No liquid in pit, 1.5' stain line noted 100 Ensign Road,Centerville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 100 Ensign Road Property Address William & Linda Burns Owner Owner's Name information is required for every Centerville MA 02563 4/2/10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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.)-. 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.): 100 Ensign Road,Centerville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a 100 Ensign Road _ Property Address William & Linda Burns Owner Owner's Name information is Centerville MA 02563 4/2/10 required for every _ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. iZcG: 0 :5 0 R 0 100 Ensign Road,Centerville•03/08 Title 5 Official Inspection Form_Subsurface Sewage Disposal System•Page 14 of 15 Commonwealth of Massachusetts _ w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 100 Ensign Road Property Address William & Linda Burns Owner Owner's Name information is required for every Centerville MA 02563 4/2/10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 12 feet. 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: refer to Topo Maps and plan on file by eldridge engineering dated January of 1982 100 Ensign Road,Centerville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 o115 LOCATION , SEWAGE PERMIT NO. VILLAGE N A LLER'S NAME i ADDRESS .6- � S U 1 DER OR OWNER t DATE PERMIT ISSUED i DATE COMPLIANCE ISSUED 40 No..... Z-y ._ Fxs. .................. • THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ___r- 04-4--.11.1.............OF...............0.4_91....... _1 __ _61P ........ Appliration for Ditivaaal Works Tnnitrnrtiun Prrutit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at: l ` . Locption-Address (' — or Lot No. � .....................� ;.--. .c. �j �f. ......... ( .0.... •�..�............/...../J T Owner Address W ` Installer Address �y dType of Building Size Lot.......... .......... .Sq. feet U Dwelling—No. of Bedrooms Expansion Attic WO Garbage Grinder (may '4 Other—Type of Building .............. No. of persons............................ Showers — Cafeteria a4 Other fixtures ............................ . W Design Flow............... ._...___._'l_ gallons per person per day. Total daily flow...........,- •.................._gallons. WSeptic Tank—Liquid capacity.��V•.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 ( ),- - GG``,,��JJ , `" Percolation Test Results Performed b ..................... . �..--A - .'�-...l�w.� 57, V ____� r Y � Date Test Pit No. L. S-.S_..minutes per inch Depth of Test Pit...... ��`_ Depth to ground water..A/jAQ (i Test Pit No. 2...-_'....minutesper inch Depth of,Test Pit.................... Depth to ground o ---•-- ------•----------- •...... ------... .��-�---- S-•--------------------------------------- Description of Soil----------------------------•-----�dL.......�2.......•--- `.. i -r --..��_M .....-------------------------•---....---......_.. W ----••••-----------------------------------•------•-----------...---•---•---------- --•-•-•--------•---•--------------------------••---------•-----.................................................... U Nature of Repairs or Alterations—Answer when applicable._.............................................................................................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of THT E 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board health. / Signed........... /ZS� `?f Z-- //�� /yr / e Application Approved By................. ,ec,�5l1.... � . ----------- Date Application Disapproved for the following reasons:--------••--------------------••----•---••-•----•-••---••--•-----•-•---•-•-----•-----..._............--------•- .....---•-•-------------------------•--------....-•------•----------•----------------------•-------.........------•-----.....-----------•----•------...-•---•----------•------------------ ---------- Date PermitNo....................................................... Issued....................................................... Date No................ ... Fxs....: .. ........... . THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH - ----------..OF................ ............... ...... .......... ............. ApplirFation for Dispae al Works Tonotratrtton 1hrutit a Application is hereby made for a Permit to Construct (,r\(or Repair ( ) an Individual Sewage Disposal System at: � �tl�...-,^ r ................ .. . ..._.........-- �f Location-Address or Lots No. ..................... `�T-a'f, .1.:'�':�....... _.Y-r-�- f -- --. e....` '._ 3.. .. ........... Owner Address Installer Address �f d Type of Building Size Lot..........p-_._/-_.._______.Sq. feet Dwelling—No. of Bedrooms........... ........:..................Expansion Attic (M0 Garbage Grinder Other—T e of Building ............... No. of persons..._............._.......... Showers — Cafeteria P4 Other fixtures -------------------------------- . W Design Flow...............la.. _.....__...____..gallons per person per day. Total daily flow_.-_-_---_-------'. .....................gallons. WSeptic Tank—Liquid capacity{�.O.O..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 ( ) �+ --'. � ( ... -G. Fd?�.. Date----•-5 �/ f Percolation Test Resu is Performed by....................._,........_............. ...........__... ... !�__._. aTest Pit No. 1........ . minutes per inch Depth of Test Pit___.__. _. Depth to ground water.__...(- ------j Test Pit No. 2__.._ minutes per inch Dlepth of Test Pit.................... Depth to ground water_.�`!�.4.A��'°� aR---.... : �" 't..-` ) �`� ---.-•---••-----••---------•-___.----- ODescription of Soil----------------------------•-.... �.?..._... _ ! �-:.r......-•...:k5'. _0 .--------------• 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'ITC:a• p of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of,health. i Signed_._.......--`=-•--?;t_4..��=----------e�� ................ Date..... . Application Approved By............ r V.t....,,,,'0 ate Application Disapproved for the following reasons:..............................................................................................................- .........................•-•-•---------------------------------------------------.....------------...------------------------------------------------------•........................................... Date PermitNo......................................................... Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........... ...E„'x.�..A,,l...OF............... 2 .. ...,rx ................... CIrdafiratr of Tantlilttanrr THIS IS TO CERTIFY, That the Inividual Sewage isposal System constructed r(-\IQ or Repaired ( ) by............................ ..-----------...................... N T sta er $ 4 f W--r-- -- ------------ has been installed in accordance with the provisions of TIT ILA j of The State Sanitary Code as described in the application for Disposal Works Construction Permit No---e.:I' .. ................. dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................. '1 .:11 ........................ Inspector..............---�.....---Z-.....-•----......--•-----------------------•---. THE COMMONWEALTH OF MASSACHUSETTS _ BOARD OF HEALTH _ l �..o��: `4 OF.................... "�r.,......................................... No...G?.. ....t�..°.. . E..... `r'�... Btopual 10orb �onorttr#ion rruti# Permissio .is hereby grantedr`z= . ...... Disposal System :_....� ................ to at No..struct r or Repair a I_0yidual Sewage d s Street as shown on the application for Disposal Works Construction Permit No..................... Dated--,�...................................... i Board ealth DATE......................................... .............. FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS a t ry 041 lop N q + 2 tp 1 3p'Y �p F Pub.L Q qb jF3 M.K p If -- _ BtChiflpy \ G•tt b '41CyA 0j, el _ 1 'h f Q �p FASEI►4M.ITN L 19 3 S.F 1r i (16 OF 4,4 I S CK=0 S.F RI> ®TEST F -E W I I7fH : I C10" of AL ER . s•B. ZC SaR S•B" 1c) R o p No.10951 O 90�FGIST�� :. g•ap FSS1ONAL � 4.I�F 6P_if"FITI-1 \ LEGEND �No M� EXISTING SPOT ELEVATION . OxO �`J'' �s CERTIFIED PLOT PLAN EXISTING CONTOUR --- 0 ——— 30 ��, L�r I ( 1=►J516�► 2c�4A FINISHED SPOT ELEVATION v is y ctitr�Qyi�� FINISHED CONTOUR 0 azl>eu c �o� �� r APPROVED : BOARD OF HEALTH I N Nos'*Rv�o �A 1;,�,8 149 1 A.51s* DATE AGENT SCALE: DATE of 14.F2 LDREDGE ENGINEERING CO. IN CLIENT I CERTIFY THAT THE PROPOSED EGISTERE REGISTERED JOB NO. 1013 BUILDING SHOWN ON THIS PLAN CIVIL LAND CONFORMS TO THE ZONING LAWS ENGINEER SURVEYOR DR.BY OF BARNSTABLE M S. 712 MAIN STREET. CH. BY: �'� 0► 1442 H YA N N I S, MASS. SHEETS OF 5- DATE . 0 LAND SURVEYOR E 20 FT. M//V. NOTF /F E/TNER THE SEPTIC TANK OR �_E.'FCH/NG GiT ARE MORE T•�' 9:`✓ /2 SELOW /rf/N. J.RA OEM �4 24'O/A M E TER C ONCR E Tc- CO i/ER BROUGHT TO 4:7,TA . �.-+,✓ EXT,?A r CDNCRETB lm. P//// 4 P/ I hEAVY CAST /A-0/Y CO{iER Sf�.4GL 3E USES =L=92.5 CODERS M/N. PITCH JF/N OR/VEN/A Y r .. PF FT. r �B R C'L EAN SANG BA CK F/L L 4"CAST u .� _ 2'LAYE'R /RON P/PE 1000 b.�I~: GAL. 0 a o a u MIN.Piruv e 1 • • • • • • • , 4 �''`:•� %4 PE�t /T SEPTIC TA/VEC • e 1 • • • o • • • • a • WA SHFO STZ7NE # •a / • D 1 1 •EFFECT/VL ` IF. • 34 :�' r e • • DEPTH • • 1 'n • v o l✓451lEO STONE . ,� s ••fie 11 • • 0 • •-• O0 p 188,S x 2.S = 4-7V E��i� • v• • • • • • • p ••o PRECAST SEEPAGE lNl�e/!'T CLE{/AT/ONS � ► • � 1 • • • • • • • a o ?/T OR EQU/V. , -74 v/D - • >=L= fig.S JNYERT AT O!//LD/NG 95,5. FT. PiTCAPtCIT`l = 549 Z= a JNLET SEPT/C TANK 95.3 FT, l� FT. D/�11►'1• C(SEETABUL4TJON> OUTLET SEPTIC TANK `15 I fT. INLET D/STR/6UT/ON BOX 94-q FT. GROuNO Hr�ITER T.4eLE OUTLETD/STR/B[!T/ON BOX 9¢.-7 FT SECT/ON OF /INET LEACHING q4.5 FT SELVAGE OISf�OSA L SYSTEM L EACH//VG =/T TABULATlD/V DES/GN Cft/TER/�l sCALE A 3 %" /= °� D/HENS/ON FT. 01M.- iV4,14fSER OF BEDROOMS 3 DIMENSION C 4 FT. M Ir-j GARQAGED/SPOSAL (/NIT tiONC SO/L LOG TOTAL E.?T/MATED FLOW 3� G.4L.�D SOIL TEST AY SO/L TEST Al SOJL TEST*2 XuMBER OF LEac///NG P/rS_I �^E[EK 9� 5 f`-A- PATE aF SO/�. TEST '�ffPT S/OF 1�.4CI•l/NG PER P/T �g Sa FT. f BOTTOM LEACHING PER P/T -lg ^ RESULTS: IV/TNESSED BY Fr 0-LI P�`RCOLAT/0/v MATE AEI L�-> M/N,//IYCK �. TOTAL LEACH//YG AREA ILG(.o S4. FT. �O�=o11-- PEVCOLA7"/ONRA7W1�2 M/N.1/NCH 1 RESERVELEACN//V6 AREA 2(0C�$Q, FT. 1,0 Nl I N/I NCH {• BAN OF AQ PS,6 `O' A4,4 MED 4,y r 2 -l 2 r�D L<=>T l I - E E,1 S I +�! �..o A C) JO o A B G `o C.; CO �QTI=Lv/t LLB E rn o MORSE �� O o p No.10951�O �� L EL DREDGE ENG/N,EFR/NG CC,INC. NpSS'Tu� p FFrS10N,4L��6 EL'g4-.S 7/Z MAIN ST. , ,1ygNN/S, "oQ-r-T NO GRO[/Nv YYi4Tt•R ENCOUNTER��O { A GROUND 1-vATE.Q AT EL EL! _ CL/ENT: L-(� JOB NO; _g(nI3 5HEET c