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HomeMy WebLinkAbout0157 GLENEAGLE DRIVE - Health 157 Gleneagle Drive A= 191 - 146 Centerville SMEAD No.2-153LOR UPC 12534 •mwl.eo.n Ysd.In USA � p �u'ow%w oaKrw SH �m Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments rib ' M 157 Gleneagle Dr Property Address _j YEU, YOUN OK Owner Owner's Name information is required for every Centerville Ma 02632 6/16/18 ' page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in atny way. Please see completeness checklist at the end of the form. Important:When �� �3��� filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Michael DiBuono use the return Name of Inspector key. DiBuono Sewer and Drain raa Company Name 35 Content Ln Company Address Cotuit MA 02635 City/Town State Zip Code 508-364-9587 SI 13522 Telephone Number License Number 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 ❑ Needs Further Evaluation by the Local Approving Authority spector'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 is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****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. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal Sys Wm•Page 1 of 17 D Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 157 Gleneagle Dr Property Address YEU, YOUN OK Owner Owner's Name information is required for every Centerville Ma 02632 6/16/18 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: ® 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 contains a 1,000 gallon septic tank. As well as a concrete distribution box and 20 Arc36 HC H2O Chambers 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. 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): l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 157 Gleneagle Dr Property Address YEU, YOUN OK Owner Owner's Name information is required for every Centerville Ma 02632 6/16/18 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ 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 ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ 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): 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 157 Gleneagle Dr Property Address YEU, YOUN OK Owner Owner's Name information is required for every Centerville Ma 02632 6/16/18 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for 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. 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 1/2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 157 Gleneagle Dr Property Address YEU, YOUN OK Owner Owner's Name information is required for every Centerville Ma 02632 6/16/18 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® 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. 0 ® 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 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 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 El ❑ 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. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 157 Gleneagle Dr Property Address YEU, YOUN OK Owner Owner's Name information is required for every Centerville Ma 02632 6/16/18 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? ® ❑ 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? ® ❑ 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)] 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 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 157 Gleneagle Dr Property Address YEU, YOUN OK Owner Owner's Name information is required for every Centerville Ma 02632 6/16/18 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: Vacant Does residence have a garbage grinder? ❑ Yes ® No 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 ears usage 217 9 ( Y 9 (gPd))� Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: Date 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 Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts r Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 157 Gleneagle Dr Property Address YEU, YOUN OK Owner Owner's Name information is Centerville Ma 02632 6/16/18 required for every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Not provided 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): l5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 157 Gleneagle Dr Property Address YEU, YOUN OK Owner Owner's Name information is required for every Centerville Ma 02632 6/16/18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 2012 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 6 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.): Baffles are in place Septic Tank(locate on site plan): Depth below grade: 4 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1,000 If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 157 Gleneagle Dr Property Address YEU, YOUN OK Owner Owner's Name information is Centerville Ma 02632 6/16/18 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 24" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 42" Distance from bottom of scum to bottom of outlet tee or baffle " Sludge stick How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.):, 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 157 Gleneagle Dr Property Address YEU, YOUN OK Owner Owner's Name information is required for every Centerville Ma 02632 6/16/18 page. Citylrown 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.): 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 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 157 Gleneagle Dr Property Address YEU, YOUN OK Owner Owner's Name information is required for every Centerville Ma 02632 6/16/18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Level and at normal level 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.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ 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. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 157 Gleneagle Dr Property Address YEU, YOUN OK Owner Owner's Name information is required for every Centerville Ma 02632 6/16/18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 20 Arc36 He H2O ❑ 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.): No ponding No break out 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 t5ins•3/13 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 157 Gleneagle Dr Property Address YEU, YOUN OK Owner Owner's Name information is Centerville Ma 02632 6/16/18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 157 Gleneagle Dr Property Address YEU, YOUN OK Owner Owner's Name information is required for every Centerville Ma 02632 6/16/18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts . 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 157 Gleneagle Dr Property Address YEU, YOUN OK Owner Owner's Name information is Centerville Ma 02632 6/16/18 required for every page. CitylTown 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: 10+ 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: 10/18/12 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: Test hole data on plan Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 6/16/2018 Assessing As-Built Cards TORN OF BARNSTABLE LOCATION 15 7 G fen eA4 I SEWAGE#10)k VILLAGEtnr_*n" fit ASSESSOR'S MAP&PARCEL J9/ INSTALLER'S NAME&PHONE NO. l LC, StTt-47rS'17 SEPTIC TANK CAPACITY /O00 (2,J LEACHING FACII,ITY(type)aAR.G���N-JO (size)o?5 X 11.5 NO.OF BEDROOMS OWNER t3 0K e PERMIT DATE: 1 0 9 ZO 11L COMPLIANCE DATE_: Separation Distance Between the: AA0 GJrCt�n/ct cyn{E✓` Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Xr C" 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 �-cnk i A-1-33 A SS A 3:+V H-µ-3oa" A-s=µ7:7" A 33 ' ' Q-d=36 , . 0 167"3=3Sd" 7 40 I I I I �O I http://www.townofbarnstable.us/Assessing/HMdisplay.asp?mappar=191146&seq=1 1/2 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 157 Gleneagle Dr Property Address YEU, YOUN OK Owner Owner's Name information is required for every Centerville Ma 02632 6/16/18 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ❑ Inspection.Summary: A, B, C, D, or E checked ❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ❑ System Information— Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 No. v Fee THE COMMONWEALTH eJF MASSACHUSETTS Entered in compute Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS application for -Misposal *pstrm Construction J)Prmit Application for a Permit to Construct( ) Repair(X Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. GL6N&V=-LE DZ dEt.JT Owner's Name,Address,and Tel.No. ow Owl YEV Assessor's Map/Parcel 14 1 44P 1 5 GCG— eA c.E DPL , CGV *MV1 Installer's Name,Address,and Tel.No. !0!9"qr?— Designer's Name,Address,and Tel.No. 5oe—3(,c4_Ogq C,ApGWtperjj%jT6KP01 (—LC GG0-TGCA4 (=—JV18otXke1JrA1% S Y �{ TR.t G(2. 54+.JOwt cc41 Type of Building: Dwelling No.of Bedrooms Lot Size 1 5 t 314.5 sq.ft. Garbage Grinder( ) Other Type of Building t!ES E~j)(_jUT[1J{_ No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 33 0 gpd Design flow provided 3 S S, o. gpd Plan Date 10—5 — a O(;L, Number of sheets Revision Date Title t 23 C;r(_WeAGLG M V E: GeF1yTTe-P_Vt1. G4,. ' Size of Septic Tank 10 00 _J Type of S.A.S. ;kO Description of Soil I mlyit.v0 s*4L& to 3G,`l /JSfX— PCAO Nature of Repairs or Alterations(Answer when applicable) USG C)(USTIOG Jooio C-44l.L6t.l 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 Certificate of Compliance has been issued by this Board of Health. gn b Date D Q °'0201 oL Application Approved by ,.> Date Application Disapproved by Date for the following reasons Permit No. Date Issued 1'j No. Fee THE COMMONWE iLT�,.Q,.f MASSACHUSETTS Entered in compute . Yes i PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS L1� _- Zippfication for Disposal 6pstem Construction Permit Application for a Permit to Construct( ) Repair(A Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot,No. tj G1.En1 C/g1C L pq, dEtJT Owner's Name,Address,and Tel.No. Assessor's Map/Parcel 191 1 44P its 1 Gc 4,-- leAct L45 nQ , C EtJ tm 0 L Installer's Name,Address,and Tel.No. 5 0S-4 7)-SKj Designer's Name,Address,and Tel.No. S Ug—3(,tE• D$9 �dPGt�,atQfa�1TC��lStiS C.t•C, GC.C�—TECt-f �'►JV(2onA�KE7-�TAt,. Type of Building: Dwelling No.of Bedrooms 3 Lot Size 1 51345 sq.ft. Garbage Grinder( ) Other Type of Building IDE�C3T([+{(_ No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3 3 O gpd Design flow provided 355, X gpd i Plan Date (O—5 — ;Z O I Z Number of sheets Revision Date Title 6:rL6Qe-AQLE VW L)15 GENTsMV/l. (5* Size of Septic Tank 000 "{,(,.p� Type of S.A.S. AO MO_ 3(r �EQDtFFi���� Description of Soil 14 9DI IdvL 5ALils / J" ser- k Ali Nature of Repairs or Alterations(Answer when applicable) V Se C X I-STI tJG loon C-r,N._Lowl son(C'T"V, ID 06k) D--[3 0 Y Tb :2 o AR4, No N! t tJ Artez-b (100 iG6 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 Certificate of Compliance has been issued by this Board of Hea th. C?Q11A R7 Date Q 9 "t�0Application Approved by ✓ /� Date 'Application Disapproved by Date for the following reasons r Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(X) Upgraded( ) Abandoned( )by e_APGU-)I n C E 0TE"IQ SZS LAX, at 1!5!1 ( E DR j U j (�-JFW LL has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer �QE(,t�fO �E�J .QIQtS S LkQ Designer F_C%—TEQ4 EF1jUlk_00A4EUjAL_ #bedrooms Approved desi ow ,33C) gpd � The issuance of this permit shall not e�cyonst ed as a guarantee that the system ill functio a ed. Date //� �sl / Inspector ------------------------------------------------------------------------'N Fee o.� / THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Disposal 6pstem Construction Permit Permission is hereby granted to Construct( ) Repair A) Upgrade( ) Abandon( ) System located at 51 G LENE 1kG Lk— 1 U t— <_eNJ TEM I(CC and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Constru ti m st be ompleted within three years of the date of this permit. l/ Date Approved b ' ` PP Y Town of Barnstable oF1ME roy, Regulatory Services ti Thomas IF. Geiler, Director MAS&STAB , ' Public Health Division t639.,erEo39rs Thomas McKean, Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Date: 1016 2t kti Sewage Permit# 2-701 L-31-7 Assessor's Map/Parcel I'll _l Installer & Designer Certification Form Designer: T�• (Oy�-4a h D wr, Installer: ra 7Atm. Address: 76014,� Address: ��►����c, OAA 02_5�3 On 20 Z 1 1. v� e,>r k' was issued a permit to install a dat ) (installer) septic system at 157 G tEnevr0e_ Dr based on a design drawn by (address) dated G; .2012, (designer) V/ I certify that the septic system referenced above was installed substa ntially according .to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Stripout (if required) was inspected and the soils were found satisfactory. t I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. Stripout (if require ected and the soils were found satisfactory. �SH OF MASs�Oti �o DAVID r,N o D. COUGHANOWIRCn (I ler's Signa ) No. 1093 (Designer's Signature) (Affix Designer's Stamp Here) PLEASE.RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. gAoffice formsWesignercertification form.doc 4 1N LOT 15 GARBAGE GRINDER ASSR MAP 191 Pa 146 \ IS NOT ALLOWED ; e� �b0 LEGEND \ WITH THIS DESIGN. 1 LEGEND Q� EXISTING BENCHM �Q 1000 GAL MARK" SEPTIC TANK TOP OF WATER GATE ELEVATION = 63.73 • EXISTING LEACH PIT BARNSTABLE GIS DATUM a I \ 6b P TST UTILITY POLE TREE 111; HYDRANT O `✓0"@-M EXISTING MINIMAL CONTOUR GRADING G / 40-, PROPOSED —40 00 I3 ®� o� ®v �2 • m 60. pN L \ \ v \ Q\ .t \\ % N,2 \ p,BOX L \ - O {t \ G 91p N 0 e e � - 1. O � TP-i q� e-� t 6�` p E R A P 1, 1 0 G rn TP-2 d�8-D- 10 0 P P�� 1v v C� \ q� 8-D - �E EM �N,1 O S�S� NC K \ 3b BpC WA TEA 'Use pc P1� ON ` /-- GATE see 0 el 000e PL AN - NOTEo �, /EoGE/ SCALE: I in = 20 ft EXISTING LEACH PIT IS TO BE PUMPED, FILLED, n 0 20 40 & ABANDONED OR REMOVED. REMOVE ANY �V CONTAMINATED STONE OR SOILS IN THE VICINITY mmmmomw OF THE PROPOSED LEACHING SYSTEM & REPLACE O 10 20 WITH CLEAN MEDIUM SAND PER TITLE 5. TOP OF FOUNDATION RAISE COVERS TO WITHIN ALL PIPE TO BE SCH. 40 PVC EL = 66.02 +- 6 in OF FINAL GRADE AND TO PITCH AT 1/8 in/ft MIN 64.80 1p D-B®� 3 ft INSPECTION USE H-20 MAX PORT EASTNG 61.84 ( U20 RATED EXISTING 1000 GALLON --_= ===ON=- _ _= �_ UNITS SEPTIC TANK 61.85 61.48 - _ -= EXISTING SEE DETAIL ON BACK EXISTING STONE SOL ABSORPTION -0 61.65 BASE 61.40 S YST E M -SEE DETAIL � EXISTING 6 in STONE B 11 ft 3-10 ft ON BACK .; CENTERVILLE. MA OFM 60.50 ADJUSTED SEASONAL 7 BELOW ~ ~ LOCUS �� ASSgC 1���jHOFMASs4 HIGH GROUNDWATER _ 54.50 3�Q o� DAVID y�� o� DAVIDSEWAGE DISPOSAL D. -' 0 U. �' ���.Tfo � SYSTEM PLAN + OQ Q COUGHANOWR �' COUGHANOWR -TO SERVE EXISTING DWELLING No. 1093 EST. ►sTE�° o,41oeNs o� YOUN OK YEU Q1995 OWNER OF RECORD 157 GLENEAGLE DRIVE NOT �-1 -7 ON CENTERVILLE,CENTERVILLE, MA TO CpR� N 0 N CDC'FO�ief �� � ' ` 43 TRIANGLE CIRCLE PROPERTY ADDRESS HE I/-. LANE H DEPIC it THIS TED ON IT.IS INTENDED SOLELY THER CHAN FCR ESATOATION 0 F THE THE PROPERTY INCLUDING DING TIC SYSTEM SANDWICH MA 02563 DATE: OCTOBER 5, 2012 PLACE ENT OF V U S M /1 P SHOULD CONSULT WITH WA MASSAACCH USETTS REGISTERED ��OWNER 1508 3 6 4—0 8 9 4 PG.1/2 1 .a8- E T E-3 6 5 6 SOL TESTS LOCH DES"Ogm, CALCULATIONS DATE OF TEST: OCTOBER 4. 2012 DESIGN FLOW: 3 BEDROOMS X 110 GPD = 330 GPD SOIL EVALUATOR: DAVID D. COUGHANOWR. LSE-461 WITNESSED BY: DONALD DESMARAIS. HEALTH DEPT- -SEPTIC TANK: 330 GPD X 2 DAYS = 660 GALLONS NO GROUNDWATER ENCOUNTERED USE EXISTING 1000 GALLON SEPTIC TANK IF IN TEST PIT 1 PERC AT 56 In - 2 MIN/INCH IN C SOILS SOWN S GALLON SETRUCTURAL OPNDITION. IF NOT.TIC TANK (MINIMUM INSTALL ALLOWED) ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER DISTRIBUTION BOX: USE 6 OUTLET H-20 D-BOX. (FEET) (INCHES) HORZC)N TEXTURE (MUNSELL) MO 64.60 SOIL ABSORBTION SYSTEM: 0-12 Ap SANDY LOAM 10 YR 3/2 NONE FRIABLE INSTALL 20 ADS ARC 36 HIGH CAPACITY BIODIFFUSERS 12-38 B LOAMY SAND 10 YR 5/4 NONE FRIABLE 20 UNITS x 5.0 ft / UNIT = 100 L.F. 61.43 100.0 L.F. x 4.80 S.F./L.F = 480.0 S.F. 38-120 C MEDIUM SAND 10 YR 6/3 NONE LOOSE 54.60 480.0 S.F x .74 G.P.D. / S.F. = 355.2 GPD USE 20 ARC 36 HC BIODIFFUSERS AS CONFIGURED BELOW NO GROUNDWATER ENCOUNTERED - Vt = 355.2 GPD ) 330 GPD REQUIRED TEST PIT 2 2 MIN/INCH IN C SOILS REFER TO DEP APPROVAL LETTER TRANSMITTAL * W000052 FOR CERTIFICATION OF ADANCED ELEVATION DEPTH SOIL DRAINAGE SYSTEMS BIODIFFUSER SYSTEMS. (FEET) USDA SOIL SCXL COLOR SOIL OTHER 64.50 (INCHES) HORZON TEXTURE (MUNSELL) MOTTLNG 0-12 Ap SANDY LOAM 10 YR 3/2 NONE FRIABLE 61.50 12-36 B LOAMY SAND 10 YR 5/4 NONE FRIABLE DISTRIBUTION BOX J36-1201 C MEDIUM SAND 10 YR 6/3 NONE LOOSE DIMENSIONS AND DETAIL USE SHOREY DB-b H-20 54.50 NOT ... TO Ib in SCALE FROM c —� /� p �p 2 TANK c 1000 (GALLON SEPTIC II ANK O � TANK TO 0 OD �': SA S O O O 7 '•.? DIMENSIONS AND DETAIL NOT TO ez�;xzczcz L_,t:?=. w. USE EXISTING UNIT SCALE A NO b in STONE BASE SEPTIC TANK IS TO BE PUMPED DRY 24 /n 2 CROSS SECTION VIEW AT TIME OF INSTALLATION AND IS TO BE EXAMINED FOR STRUCTURAL INTEGRITY. INSTALL NEW PVC OUTLET TEE EQUIPPED WITH A GAS BAFFLE. S 0§L ABSORPTION I in Q SYSTEM CONSTRUCTION Tt8ft-6 DETAIL a USE ADS ARC 36 HC BIODIFFUSERS GRAVEL APPROVEDRINSALLALTIONPROCEDURES. INSTALL TWO INSPECTION IINSPECTION PORTS AND INDICATE o PORT LOCATION ON AS BUILT CARD to 25.0 ft in � o INLET OUTLET COVER CO VER o loe3 IN DROPFLOW LINE 20 UNITS TOTAL — 5.0 ft PER UNIT BUILDING _ 10 In = 141 TO In D-BOX IO CROSS SECTION VIEW 48 in RESTORE VEGETATIVE COVER LIQUID GA BACKFILL WITH CLEAN PERC LEVEL BAFFLE SAND TO TOP OF CHAMBERS SEPARATION OF INLET AND OUTLET TEES SHALL BE NO LESS THAN LIQUID DEPTH 10.75In HI-CAP EFF DEPTH UNITS CROSS SECTION VIEW EXISTING z 2.875' SUITABLE MA TERIAL EFFECTIVE WIDTH = 4 x 2.875' = 11.5' USE 4 ROWS OF 5 ARC-36 HC ADS BIODIFFUSER UNITS-NO STONE NOTE-S ' ` 1) INSTALLER TO OBTAIN DISPOSAL WORKS PERMIT BEFORE STARTING WORK. 2) ALL COMPONENTS INSTALLE6'SHALL -MEET -THE MINIMUM REQUIREMENTS OF MASSACHUSETTS TITLE 5 SEPTIC CODE (310 CMR 15). SEWAGE DISPOSAL SYSTEM PLAN 3) INSTALLER TO VERIFY LOCATIONS OF ALL UNDERGROUND UTILITIES PAGE 2 OF 2 BEFORE EXCAVATING FOR. SYSTEM. 4) PIPES EXITING D-BOX TO-RUN LEVEL FOR 2',FEET- BEFORE PITCHING DOWN. 5) ECO-TECH ENVIRONMENTAL RECOMMENDS'.THE INSTALLATION OF LOW FLOW Y O U N OK Y E U FIXTURES & APPLIANCES. AND BIANNUAL THE SEPTIC TANK. D ISESINED TO 157 GLENEAGLE DRIVE 6) SPARKMOR DROIVEDVEHICICLES OVER ISEPT THSTA C-.SYSTEM.ULAR LOADING. DO NOT CENTERVILLE, MA 7) SEPTIC TANKS TO BE INSTALLED LEVEL AND TRUE TO GRADE ON A LEVEL STABLE BASE THAT HAS BEEN MECHANICALLY COMPACTED AND ON TO WHICH OC.TOBER 5, 2012 1 ETE-3656 SIX INCHES OF CRUSHED STONE HAS BEEN PLACED TO MINIMIZE UNEVEN SETTLING. Town of Barnstable P#_ 7, Departiment of Regulatory Services MAE& , F Public Health Division Date : a� jEo tauct� 200 Main Street,Hyannis MA 02601 ` Date Scheduled zb_ ) a-, Time Fee Pd., Soil Suitability Assessment for Se e Disposal Performed•By:NVIO 0 . CbUGHA-Vj0Wz. SSE Witnessed By: 6k l LOCATION& GENERAL INFORMATION Location Address 1 5'7 C—1:.W AGcG Pk(06 Owner's Name Address '151 &C—NO-W; L.E wz 0- [LLC Assessor's Map/Parcel: (.' /j q0 Engineer's Name �40�1a,101✓ tWC�3t/� NEW CONSTRUCTION REPAIR _ -'Telephone# fs J� ','f�7 9�7�. Land Use: R e52 6{QII,+:q ppq W yl /" �Slopes m `-' Surface Stones D►'l 19 Distances from: Open Water Body `00 + ft Possible Wet Area p o ft Drinking Water Well LY♦ft . 1 Drainage Way 50 t ft Property Line '© ¢ ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&pere tests,locate wetlands in proximity to holes) too, 03cE tbp•Oo fL hLC_NL- RGLL 'D R L u c- Parent material(geologic) POl��gGi (�tJ}tNq 5 h Depth to Bedrock IA 04 e Depth to Groundwater. Standing Water in Hole: A 0 k t? Weeping from Pit Face 11 ItL° Estimated Seasonal High Groundwater MO I`a +i R h DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: n'i Depth Observed standing in obs.hole: __ —In. Depth to Soil mottles: + in, Depth to weeping from aide of obs.hole: In, Groundwater Adjustment fl. Index Well# Reading Date: Index Well level:_ ..._„ Adj,factor..,,,,,, Adj.Groundwater Level,,, PERCOLATION TEST bate 1014/1 Thne ►o R M Observation /9 Hole# Time at 9" h Depth of Pere Time at 6" Start Pre-soak Time Cal '6 Time(9"•6") [ 'r End Pre-soak t -o 0 Rate Min.Anch P 1 I Site Suitability Assessment: Site Passed ` Site Failed: Additional Testing Needed(Y/N) N Original: Public Health Division Observation Hole Data To Be Completed on Back-------- ***If pecrc6lation test is to be conducted within 100' of wetland,you must first notify the Barnstable Conservation Division at least one(1)week prior to beginning. Q:ISEPTICVERCFORM.DOC DEEP-OBSERVATION HOLE LOG Hole# 1 Depth from Soil Horizon Soil Texture .Sdil Color Soil. Other Surface(in.) (USDA) (Munsell Mottling (Structure,Stones;Boulders. U ' 1 Z R P � � to _Y.96 Oraven ��"akd- taAW �0�� 3�2 �oKe �u�yColr �I;--I20 �e�iv»t Spa 10 `� R �l II t �c5 e DEEP OBSERVATION HOLE LOG Hole# 7- Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. ' e 4p &ad Login, (DER 3�2 �Jv><P L,4 ,Nd 10'fR S/4 `' fir; q blQ q26 - 1 0 .C. ``'1ec.ln G,1114l� `(R ��. �' Loose DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Sol]Texture Sol]Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistenev. DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon 'Soil Texture? Soil Color Soil Other Surface(in.) (USDA) J - (Munsell) Mottling (Structure,Stones;Boulders, Consistenev. a Flood Insurance Rate MAR: / Above 500 year flood boundary No_ Yes Within 500 year boundary No Yes ' Within 100 year flood boundary No.✓. Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system?If not,what is the depth of naturally occurring pervious material? Certification N J , 16115 I certify that on (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consist the requir training,expertise annmod,experience•described in�10 CMR 15.017. r+OF MgSs �. �.��: # �1 �f 5, Zo12 DAVID 9cyG� Signature Datt: o� D. " COUGHANOWR 00 4/CENS�� Q O Q:\S,EFTlC1PERCFORM.DOC EVALUP� /< TOWN OF BARNSTABLE LOCATION 157 G fen e-.y le, 13 SEWAGE#20, VILLAGECerl f rZj ASSESSOR'S MAP&PARCEL 4 INSTALLER'S NAME&PHONE NO. — (C. yce-a77-ka77 SEPTIC TANK CAPACITY I000 G LEACHING FACILITY.(type) aO Ap�,C 36 NC H-A (size)o? X NO.OF BEDROOMS 3 i OWNER l e'V n 01< /eU PERMIT DATE: 1010, Z.® j y COMPLIANCE DATE: iQ $ l0, Separation Distance Between the: /V® G MQ—►el crJ-f e✓' Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility&CAzwk at l38 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 VS4;1k, r A-s1=33 A-3=LW A-4-.30 f v � 6_a=36 7 e , -�"- 1 * I � .5o � � t 0� o. G7 ... ... FEB...... ...................... THE COMMONWEALTH OF MASSACHUSETTS BOARD - OF HEALTH TQ .......-....OF.....12AI,2�.. rxegl"��........................ 1 "Appliration for Diipu, i al Murky Tunutrnrtiun ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: • ........��_ f1� 1� '4�...----- . ....... .............. ..O./T---.........1 .5'............................................... Addc*rr or ....Locat, ..............•............................. Lot No. Address Owner ------------------•-----_•-•• W ' Installer Address d Type of Building Size Lot...6L_3..`/._KSq. feet U Dwelling—No. of Bedrooms_______________-..._.._.. ._ Expansion Attic ( ) Garbage Grinder ............... No. of ersons...._....................... Showers — Cafeteria Other—Type of Building ............. p ( ) ( ) a' Other fixtures ............................ W Design Flow............ .....................gallons per person per day. Total daily flow..............0.. 0_.-....__..._..gallons WSeptic Tank—Liquid*capacity�W� allons Length_K_.�_._. Width..`/.._Z�.. Diameter.�!-f.._�...- Depth.>�._�.-- x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No......../........... Diameter_._.__......... Depth below inlet....._�a............. Total leaching area..a q®..sq. ft. z Other Distribution box (P*) Dosing tank ( ) Percolation Test Results Performed by....C"_1__9.......... _________________ Date..... .Q .......... Test Pit No. 1.:!�__�i.....minutes per inch Depth of Test Pit-----lam........ Depth to ground water___ _a1 . Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-___-______.-__..-______ -------------r---------------- -••----------- -----------------••----•........._.......-----.....-----....----•------•----•-------•-•---------------_----- O Description of Soil........O.-7,/J.............% _ Ut' ... --...------------------------------------- l �'a."r' L ' L.D �� � /. ------ - - ----------------------- --- --------- W =-/ / 'e V�.� ,F /-�.. -------------------------------------------------------------- UNature of Repairs or Alterations—Answer when applicable............................................................................................... ----------------------------•--------------•----------------------------------------•-••----••-•--•-----------------------------------------•--•----------------------••---------------------._......._. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with ITT 5 of the State Sanitary Code— The undersigned further agrees not to lace the system in the provisions of �_::..: y g g p y operation until a Certificate of Compliance has been issued by the board of health. Signed Ro ' "=-------- • •---.. --- Date Application Approved By...... 690- Date Application Disapproved for the following reasons---------------------•---------------------------------------------------------------------------------......_... ` � Da t e Permit No......................................................... Issued--- `� - �` -`�---`= ....-•----•------- Date ' , ti 00-�K? --- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Appliratiun for lliipuual Works Tontratrtiun Prrutit Application is hereby made for a Permit to Construct ( )" or Repair ( ) an Individual Sewage Disposal System at: / yJ Locati n-Addle s or Lot No. Owner Address W .....----It % ,�- ........................................ .................................................................................................. ►a Installer Address � f Type of Building Size Lot..� ,__2__�?_��_-Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder (1/0) 4 Other—Type e of Building No. of persons............................ Showers — Cafeteria 0.1 yP g P ( ) ( ) Q' Other fixtures ............................ . WDesign Flow............�`�. ------_-__--------_gallons per person per day. Total daily flow.............. .. _0...............gallons. WSeptic Tank—Liquid'capacity/Pa�&allons Length..>__... � __._ Width..Y._fa.. Diameter.--A:.�.... Depth.S.-?._..' x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No......../---------- Diameter......0-_--_____- Depth below inlet-----_f2__.......... Total leaching area..4.2a9..sq. ft. Z Other Distribution box (!,,o Dosing tank ( ) s ~' Percolation Test Results Performed by----K" _i"..._.....sS./1Od?. ................... Date..... _'g.,Z.......... ,aa Test Pit No. 1_ __ c-___minutes per inch Depth of Test Pit____1A........ Depth to ground fi Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water--_____-___-----------_: a ------------->----------------------------------------------------------------.._..........._------......................................................... 0 Description of Soil••••--a./4.;.------•--.,$' - dl ---------------------------------- ---------•----------------------------------------- -7-=_ W - ------------------------- .� ........ 1 F ` �, � � UNature of Repairs or Alterations—Answer when applicable----------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------•--........------------------------...---------------------------------------------------------------•----•--- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with < n-rT the provisions of .i::..� 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 of health. Signed------------••---•-•----------r------------------------------------------------------- --------------------------- Date Application Approved By._...-= t97" f ._ _e.../ ,, CE 1. ;,.t� f� Date Application Disapproved for the following reasons-----------------------------•---------------------------------•-----------------------------------------........ ---------------------•------------------...-•--------------------------------------------------------------------•--------------------------------------------------------------------------------•-•--- Date PermitNo........................................................ Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............TO%r-!A V.......OF.... .................... Trrtif iratr of TontpliFatta THIS IS TO CERTLE Y, That the Individual Sewage Disposal System constructed or Repaired ( ) by-•••-••---------...AC ------ ---------------------------------->................................................................................................... 1 Installer at.--------- --- -•-5-•-----• ------ � t . has been installed in accordance with tie provisions of TIZL j of The State SanitaryIU�ARANTEE de as described in the application for Disposal Works Construction Permit N ..- G--..__3_6_,................ da.ted_. on----/�_-_.�-!�-_-_-_------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A THAT TIME SYSTEM WILL FUNCTION SATISFACTORY. ,�-� a `l / '� DATE..:. --- '� Inspector •------------•-•............. r• .... ---..._----•--•............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH _.. FEE._1A....-•-•----• Disposal orko 01Auntrnrttion rrntit Permission is hereby granted--------- � a '` is V .... to Construct (,Kor Repair ( ) an Individual Sews e Disposal System atNo................. ....... =..... -11.,..------... � ..------•--- ................................. Street as shown on the application for Disposal Works Construction P mit� Dated. • GLt _ _ ----------Vic••--WZ� -------- -------------------------------------- Bo r of Health DATE---- ..- .................................................. B��f 1255 HOBBS & WARREN, INC., PUBLISHERS LOCATION lS SEWAGE PERMIT NO. /57 e L F F`I G L� 12e Vi-LLAGE fir-jy 7lF,2 y cL U 6 INSTA LLER'S NAME & ADDRESS BUILDER OR OWNER 0 x2 7 DATE PERMIT I S S U E D DATE COMPLIANCE ISSUED _ �� �� 3�O 10 s• /1 T tom} AtJ. 9 , 7-01::1 Sr>1. j*,v4 �_... " F, s'to ,7 ,~ /Z ' /4`I 7?/vr-, 5�r�✓i7 SDK f.4� Q � 4-6 . . vj TA L It v NL SEZVE s 1 , Ff '" �/ti/MC/27 SCALE 13 u/LD/rvG S ETL3�C� � f U/,2�MF_�l/7� F20NT 5i DE /p O2O PO SED ' 3 .BED 2ooMs SE P T/C 5 y5 TE M CG7NS 7'2 L./G 7/0,Aj SHA , /. COnIFOIzM To MASS • 0e-S/GN FLOW 3 3 © GAL/D,4 y ENV/eO/VML-NT/�L CODE 7/7 -f- JZ /S rJ %,�. 't 77 f Fr 1'rd i✓��f L ,� G/-/ 2.4 TE z , . f,,. P G A C_�Dr3 O �/EALTN TZEflJL.AT/0NS ,020F�05ED LEACZ- }(„ F .` �;/, JP;f Y 2/4 /MpL-�✓/OUS COV6Ae • MANHOLE �Co✓ET2. TO EX TEAlD 7'O TO ,a2C t/E,UT YV/ Ti//N /' OF F/N/SA1 Eta GIZA DE; F2Or�-! /NF/LT2,4 7/A/C D/5 T. co vEz z%6,eAr1f 13OX I �I \Z/"WipE 0IleR 4'CAST/,Zon/ _�r _ F 3"M1AJAlu PiT MPiTG�M � �,Ave '� M� T/Gir 46 Dia. �-� /O L�qc</ 7�4 / /Q"Mr n/ / AcMrni �i r cfi T '2LVA/�? %4 /.Cool 5 NECYMiN 1 ,-r" _ /.vv�r / 7.6 3 � o lvE 4GALLON/ /N✓E.eT �� i— /n/vE.2T CA PAG•/ TY A120Unto , 6E,C->r/c TA V& /7 B 0 33 rc I ELEv. SOTOM Of� n� C!n/,ATG"27-1 A/7 /nJVLZ7- P/T / r /IV V E r2T - AJO GA.C-16A6E �rz/nfDE� _ t /�� 33 r SITE , PLAAJ cl, SHORT --r--„f,7;., -;qi UUTLETS � AND LEAGN/NC F�/T Na ?74E3 4, 8E c'�F �Er�/F42�E� GO.VCl�G7E 5 > a G�n1G`2E TE S T-2G�/G 3000 Psi M/�v 20000 13Y CZOL E-1-. TAYLOR COjep, �-/- /o Low D/.v6 8� W 1G L.O W y-S7,E E rz� Ui�/v'E y vA Y ITT TO E3 4 L �- o v�e s ys re M utic s �i- 20 f C E,-T I F Y THE FO L/A.1,75A 7"iOA,/ S1--/OWAv On/ TNi S r'L 4&r IS C X l S rleV e,- OAJ T/-/ (300 0"2D /15 5/;'cam Gt N DOES � C.EOPG r flivz7 r 7 �7tiI�L` kb'/7' o `4w, t ,�j OF — -704 �' OF �71'T lT�V *v7 I /"J �d.4 ,/�"lf`$. \�/� �O SU#�d rL�� � C>A T-� A/E/IL77-/ A�E�c/T