HomeMy WebLinkAbout0050 GUILDFORD ROAD - Health 50 Guildford Road
Centerville P: '
A = 172 060
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UPC 12534
No.2 53LOR
HASTINGS, MN
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
MAP r12
PARCEL Lw6 S .
TITLE 5 'LOT 7 a 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM '
PART A
CERTIFICATION
Property Address:tad 6;,1 Tr--t z)Fbar-) P—A
C-E&tMLZ= = 111,27'-
Owner's Name: Qn VC Lt�y t
Owner's Address: �'g_:- 6 pJ
Date of Inspection: / E D 3 MAR I E` 2003
LEARY
Name of Inspector: (please print) HENRY J. TUv'v(J:��
Company Name: SUPERIOR HOME INSPECTIONS
Mailing Address: P.O. BOX 544
CARVER , MA - 09310
Telephone Number: Fton 44b_3331
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 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:
basses
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails /
Inspector's Signature: Date: /�3
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.
Notes and Comments
****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.
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Title 5 Inspection Form 6/15/2000 page I
Page 2 of I 1
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORK!
PART.A
CERTIFICATION(continued)
Property Address:
ca—
Owner:
Date of Inspection: /- �—S�' a`k;
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
l have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CNR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
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 bspW ich 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 kvcl in the diwibufm box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass kLSPCCti0n if(with
approval of Board of Health):
broken pipes)=teplarcd
obstruction is removed
distribution box is leveled or raplacW
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:
2
ti
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR PECTION FORM ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INS
PART A
CERTIFICATION(continued)
c
Property Address: �� ,�� "`'`�
Owner:
Date of Inspection:
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 15303(lxb)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.
_ 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
facity and
bacteria and volatile organic compounds indicates that the well is free from pollution from ttino oother
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 pm,provided
failure criteria are triggered.A copy of the analysis must be attached to this form.
3. Other:
s
3
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION O
Property Address: S ie(
�yL�
Owner-
Date of Inspection:
D. System Failure Criteria applicable to all systems:
You must indicate`yes"or"no"to each of the following for all inspections:
Yes No
LZ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
1' Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
t/ Static liquid level in the distribution box above.outlet invert due to an overloaded or clogged SAS or
cesspool
LZ 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.
1G 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.
�L Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_ 4/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 passesfifttt1ewsil water anziysis,
performed at a DEP certified laboratory,for coliform bacteria.and volatile organic compounds
indicates that the well is free from pollution from that facility 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.]
(Yes/No)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 design f e"t 10,000 gpd to 1SA00
gpd•
You must indicate either`yes"or"no"to each�uf the ful awiag:
(The following criteria apply to large systems iri addition to the a>haraatO )
yes no
_ the system is within 400 feet of a surface drbiking 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.
4
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
Owner:
Date of Inspection:
Check if the following have been done You must indicate`yes"or"no"as to each of the following:
Yes N
Pumping information was provided by th caner o cupan r 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?
_ ave large volumes of water been introduced to the system recently or as part of this inspection?
t/ 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?
a
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:
Yes no
(� 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 CNM 15.302(3)(b)]
Page 6 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:—7�Z_z -�•�- ' � /&
Owner:
Date of Inspection: T of 03
FLOW CONDITIONS
RESIDENTIAL
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): I,3n e' ,47.D
Number of current residents: ,2— `/ .
Does residence have a garbage grinder(yes or no):Ls
Is laundry on a separate sewage system(yes or no):, o [if yes separate inspection required]
Laundry system inspected(yes or no):_
Seasonal use:(yes or no):No
Water meter readings, if available(last 2 years usage(gpd)):g3rrs� =D
Sump pump(yes or no):hQ
Last date of occupancy:
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): ppd
Basis of design flow(seats/persons/sgf,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no):_
Non-sanitary waste discharged to the Title 5 system(yes or no):_
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: �rgruY — a r..D.v�rL
Was system pumped as part of the inspection(yes or no): /8 0
If yes, volume pumped:_gallons—How was quantity pumped de2rr*ed?
Reason for pumping: ry o wG op g!E= ==t+= �- -T�•.
TYPE OF SYSTEM
ln�eptic 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/Altemative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight tank _Attach a copy of the DEP approval
_Other(describe):
Approximate age of all components,date installed(if known)and source of information:
off- a 9--Z'
Were sewage odors detected when arriving at the site(yes or no): �LD
Page 7 of l l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection: / - s _ C 3
BUILDING SEWER(locate on site plan)
Depth below grade: _
Materials of construction:_cast iron 1,f4 PVC_oth r(explain):
Distance from private water supply well or suction line: 0 /1~
Comments(on condition of joints,venting,evidence of leakage,etc.):
T0:C-1Q —S IO JE�pgD y � =
SEPTIC TANK:ks(locate on site plan) �oL�
Depth below grade:fAP/&)6• l-0
Material of construction: L---66-ncrete_metal_fiberglass_polyethylene
_other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no): —(attach a copy of
certificate)
Dimensions: �/G1�OGAL TArylc- l /5do �9L•-r.9rva- /i
Sludge depth: ooD =�/vao�L y
Distance from top of sludge to bottom of outl to r baffle:rw ieao -..�.,ri� •S�PP�x. a
Scum thickness:/COOCo,9L - .2 ,3 Dom-
Distance from top of scum to top of outl to or baffle:/ iLA1 7Ww1C- b�""
Distance from bottom of scum to bottom of outlet ei, r baffle:AoDW1C. /3 ' .Z3o"T�t
How were dimensions determined: Im 4-9 y ;'4
Comments(on pumping recommendations, inlet and outlet tee or baffle condttton,structural integrity,liquid levels
as related to outlet invert,evidence of leakage, etc.):
P CA -►-.+� '— o - T - - -
TAW v �t�r,�+-�L7 iC.•z0 c.�D L�yc• � '���s� ?i�r1J.�S
,E�Jy L ,4T ovl L�'T �N�l� /Yv �A'K/��E•
GREASE TRAP/(locate on site plan)
Depth below grade:_
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:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
Page 8 of 11
OFFICIAL INSPECTION FORM—INOT FOR VOLUNTARY ASSESSMENT'S
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: .—0 _
Owner:
Date of Inspection:
TIGHT or HOLDING TANK: (tank must be pumped at time of inspectionxlocate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX:L\IICJ(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:0
Comments(note if box is level and distribution to outlets equal,any evidence of soBds carryover,any evidence of
leakage into or out of box,etc.):
furl+ 6094E s I F=VCL,TQ0-4 L Qr-Q-'; .ua GA22s�DvCi'� . A.)!D
PUMP CHAMBER:40+(locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber canditm of ponps wd zppm1cnanccs,etc.):
8
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: -C
Owner:
Date of Inspection: /- 2-r- a
SOIL ABSORPTION SYSTEM(SAS): as(locate on site plan,excavation not required)
If SAS not located explain why:
Type
1/ leaching pits,number:�/Aoe-zFw t T�5'r✓�
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.):
S o� o0 0 64 L.
?� 3 S1 A C=LDW SJ'vy�� o..� /Suc� G.Qc- T�,vt_ L}/aEcoc.o
�,4vc�T
CESSPOOLS:A(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 or no):
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
PRIVY:h4(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.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM—NOTFOR'VOI.iMARV ASSESSMENT'S
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(contimmd)
Property Address: SZ
Owner:
Date of Inspection: - y�
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.
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Page 11 of 1 I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: So
Owner-
Date of Inspection: /—. o'>
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground waterer feet
Please indicate(check)all methods used to determine the high ground water elevation:
Ob ined from system design plans on record-If checked,date of design plan reviewed: Zf
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:
11
C-O-MM WATER DEPT
CUSTOMER STATEMENT
ACCT NO 6,296 1/28/03
LILLY,BARBARA&TENNIS
LOCATION:
50 GUILDFORD RD
CEN
LOT: L178
MAP&PARCEL : 172060
Consumption History
DATE READ CONS
12/31/02 1653 102
06/30/02 1551 58.
12/31/01 1493 103
06/30/01 1390 75
12/31/00 1315 116
06/30/00 1199 49
12/31/99 1150 113
06/30/99 1037 47
TRANSACTION HISTORY
DATE. DESCRIPTION 0 to 30 31 to 60 61 to 90 Over 90
10/2/00 MINIMUM BILL 0.00 0.00 0.00 15.00
10/23/.00 PAYMENT 0.00 0.00 0.00 -15.00
1/l/0l MIN EX 0.00 0.00 0.00 293.40
3/3/01 INT 0.00 0.00 0.00 3.42
3/19/01 PAYMENT 0.00 0.00 0.00 -293.40
4/2/01 MIN 0.00 0.00 0.00 15.00
4/17/01 PAYMENT 0.00 0.00 0.00 -18.42
7/2/01 MIN EX 0.00 0.00 0.00 174.50
7/30/01 PAYMENT 0.00 0.00 0.00 -174.50
10/l/61 MIN 0.00 0.00 0.00 15.00
10/17/01 PAYMENT - 0.00 0.00 0.00 -15.00
1/l/02 MIN EX 0.00 0.00 0.00 255.70
Balance Due: 0.00
C-O-MM WATER DEPT
CUSTOMER STATEMENT
1/30/02 PAYMENT 0.00 - 0.00 0.00 25-5.70
4/1/02 MIN. 0.00 0.00 0.00 15.00
4/24/02 PAYMENT 0.00 0.00 0.00 -15.00
7/1/02 MIN EX 0.00 0.00 0.00 145.20
7/26/02 PAYMENT 0.00 0.00 0.00 145.20
1/1/03 MIN EX 272.80 0.00 0.00 0.00
1/23/03 PAYMENT 272.80 0.00 0.00 0.00
Balance Due: 0.00-
'� F��i >�a �. L ��y,�ry,-- -'�'.'".�.��ri!,Yrr '� t- �. . t N� �^.'�+1. o! r '^§. .. - �•'
1 mu't,..�'Y'. .peCSLli •..
COMMONWEALTH:OF3XA3SACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION ;_
ONE WINTER STREET,BOSTON MA 02108 (617)292-5500
WII.1"F.W S TRUDY COXE
ELD
Governor ��, Secretary
ARGEO PAUL CELLUCCI DAVID B. STRUHS
Lt.Governor Co•^**++sstoner
,r�d SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
t`'l Q 1 PART A
L'o 0 CERTIFICATION
Property Address: a u-`asro*A t CGt�Tvw�1►-C� Address of Owner: �L -.V—C„-t>Wu"$.'+,►.-I
Date of Inspection: `'2 o`c (If different)
Name of Inspector: NA t
I am a DEP approved system inspector pursuant to Section 15-W of Title 5(310 CMR 15.000)
Company Name: ."V L
Mailing Address:0.t-) . �X �N���- H I%r-C . M,�
Telephone Number: CA-j-1- I
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
Needs Further Evaluation By the Local Approving Authority
Fa's A n
Inspector's Signature: C YN_(� Date: Azz\ot�,
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 and copies sent to the
buyer, if applicable, and the approving authority.
INSPECTION SUMMARY: 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.
COMMENTS:
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.
Indicate yes, no, or not determined (Y. N. or ND). Describe basis of determination in all instances. If'not determined', explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection. or the
septic tank, whether or not metal, is cracked. structurally unsound, shows substantial infiltration or exfritration, or tank failure
is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming`scptic tank as approved
by the Board of Health. f
(mised 04/25/97) Page 1 of 10 ✓/
.r.
9 d
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
k
'CERTIFICATIONcontiaued)}';t�S!�'
Property Address:
Owner:
Date of Inspection:
BI SYSTEM CONDITIONALLY PASSES (continued)
_ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or
due to a broken. settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health).
Describe observations:
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(s)are replaced
obstruction is removed
CI FURTHER EVALUATION IS REQUIRED BY THE BOARD,OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health. safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETER.IMYES THAT THE SYSTEM IS NOT FUTCTIOND;G IN A
. MAINNER WI-UCH NN7LL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONNIE?NM
_ Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE)
DETEILtiiINFS THAT THE SYSTEAf IS FUNCTIONING IN A NIANNER THAT PROTECTS THE PUBLIC HEALTH AND .
SAFETY AND THE ENVIRONMENT:
_ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or
tributary to a surface water supply.
_ The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
_ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private
water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is
free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm.
Method used to determine distance (approximation not valid).
3) OTHER
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SUBSURFACE SEWAGE P!SPO§AL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
DI SYSTEM FAILS:
You must indicate either 'Yes' or 'No' as to each of the.following:
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.
Yes No Backup of sewage into facility. ... or system component due to an,overloaded or clogied'SAS or eesspool.
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 lC5S than 6" below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
Any portion of the Soil Absorption System. cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet-but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria. volatile organic compounds. ammonia nitrogen and nitrate nitrogen.
El LARGE SYSTEM FAILS:
You must indicate either "Yes" or *No" as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility 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-.
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)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(mised 04tZS/917) Page 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM IIVSPECTI ON,
PART B
CHECKLIST` - .
Propert Address: 50 CR..(d ^
Owner: 11tNN p't
Date of Inspection:
You must indicate either 'Yes' or 'No'as to each of the following:
Check if the following leave been done:
Yes No
Pumping information was provided by the owner, occupant, or 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.
_ As built plans have been obtained and examined. Note if they are not available with N/A.
_ The 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.
X _ All system components, excluding the Soil Absorption System, have been located on the site.
_ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or
tees, naterial 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:
�( The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-
���""""` Surface Disposal System.
Existing information. Ex. Plan at B.O.H.
_ Determined in the field (if any of the failure criteria related to Pan C is at issue, approximation of distance is unacceptable)
(15.302(3)(b)l - -
(rer[sed 04/Z51" rage 4 of[o
,i
+i,..f- T .NF7 , • _ ' IiKiJRIJ � '. '31 .: 5` �Li q#JI j�� .
SUBSURFACE SEWAGE DLSPOSAL SYSI'F.M INSPECTION FORM
raitiru: rr..rrMART C -, ,`'r,3T: `
SYSTEM MORMATION
Property Address:
Owner: %Nr.4 o
Date of Inspection:
�J► l FLOW CONDITIONS
RESIDENTIAL:
Design flow:_W.M) g.p.d.l.bedroom for S.A.S.
Number of bedrooms:j23
Number of current residents: a.
Garbage grinder (yes or no):,
Laundry connected to system (yes or no):
Seasonal use(yes or no): 6,S
Water meter readings. if available(last two(2)year usage (gpd): hp
Sump Pump(yes or no): N
Last date of occupancy:
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow:_ allons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)—
Non-sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings, if available:
Last date of occupancy: '
OTHER: (Describe)
Last date of occupancy:
GENERAL M'FORINIATION
PUNIPr G RECORDS and so cc of inF, ntation: -�-
NO
System pumped as part of inspection: (yes or no)
If yes, volume pumped: gallons
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)
I/A Technology etc. Copy of up to date contract?
Other
APPROXMIATE AGE of all components, date installed(if known) and source of information: VS sA
Sewage odors detected when arriving at the site: (yes or no)
(revised OV251" Page 5 of 10
� :, T �?S..L� ��[$,�f ^s� "` ✓y+�� e �' �d•4'� t9s��� 'Mb* •yn,,.' '�i^l A' -,:, •*`,, k!;_V..
'/ � G �a k ;L"r � �'a• �rt�7� � � ri«ry..- Y��i Li/^,— 'tits',
:k� ., - �. rX Ta�Y �w 15" 7;/,xb i r,:• " si�- � �. � TN ¢ ,6 ��p.�ir.`y,,+r+ �''.Y� .� � � _ ,r.,
., _ .;:�.�+ � , _ i s,�. �*9•;�,�yea. �v ; f�
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
SYSTEM INFORMATION (continued)
Property Address: ejo rQut
Owner: 614t*.a1,a Prt.1
Date of Inspection:�`�
BUILDING SEWER:
(Locate on site plan)
Depth below grade:
Material of construction: _cast iron_40 PVC_other(explain)
Distance from private water supply well or suction line
Diameter
Comments: (condition of joints, venting. evidence of leakage;etc.)
SEPTIC TANK:2
(locate on site plan)
Depth below grade:
Material of construction: lconcrete _metal _Fiberglass _Polyethylene —other(explain)
If tank is metal, list ape_ Is age confirmed by Certificate of Compliance _(Yes/No)
Dimensions: ( — K009w 1 *Z— \OO O nw
Sludge depth:S\ 3" Z`W' �t r
Distant from top of sludge to bottom of outlet tee or baffle: Z
Scum thickness:It\-u„ A 1"13, *6- t�
Distance from top of scum to top of outlet tee or baffler,—.%A 2"�
Distance from bottom of scum to bottom of outlet tee or baffle:
How dimensions were determined:1jV�n.>uL„ss`�
Comments:
(recommendation for pumping. condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet ' ven. structural integrity.
evidence of leakage. etc.)
W u ~
GREASE TRAP:
(locate on site plan)
Depth below grade:
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:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert. structural integrity. {
evidence of leakage, etc.)
(revised 04M/97) Page 6 of 10
T, y
'' 3 .' y' IFay'"r ? 'rf;••�faY'
�
? yz •A4_' � �fy,+y'd.
NCO? fti:'I 3T}ri:l•F{ 22r!� ?r„ 42,:! 3s)h`l! }
--Ij 9
SUBSURFACE SEWAGE DISPOSAL gSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: Uty
Owner: f}�
Date of Inspection:
96r%
TIGHT OR HOLDING TANK:_(Tank must be pumped prior to, or 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/day
Alarm level: Alarm in working order_Yes: _ No
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches. etc_)
tISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert: yu4"' l o.T4Z'
Comments:
(note if level and distrtbuttRn is equ�1. evidence of solids carryover, evidenc f leakage into or out of ox, etc.) .
� �h A 4=( �1�LS� t t Q-t aw �c, t l �! Wks SzThd a V'V-�j n e e
PUMP CHAMBER:
(locate on site plan)
Pumps in working order: (Yes or No)
Alarms in working order (Yes or No)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 04R5/97) Page 7 or 10
t � �t -q'Y�c �f.{. X_ s i35nd L nF� � 1 '•�� .v� � �- ���.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
sa
B C
r t�
21 c";LIf - '
SYSTEM I NFOR ON (cont nuedi
Property Address: al)1 •
Owner:
Date of Inspection:61ZP
SOIL ABSORPTION SYSTEM (SAS):
(locate on site plan, if possible; excavation of required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type:
leaching pits,number:_A `(oX(o
leaching chambers, number:_
leaching galleries, number:
leaching trenches. number,length:
leaching fields. number, dimensions:
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc
s �
CESSPOOLS:.. }
(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 (cesspool must be pumped as part of inspection)
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.)
(revised 04aS/97 Page a of 10
Og*7,
!g
7
...........
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PAMC
SYSTEM INFORMATION (continued)
Property Address:50 r,,,-,ka-RAd
Owner:
Date of Inspection:8\10
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
3 Z l SO
VL
Lk
Ea- f6
a3
E;5- XY
A+30 U-\ 33'
(mvised 04/15197) Page 9 of 10
� � >�*ia�' s•� `� i� �, �{6 l�'4���r s�`4 y�c`' - + w s• h.;;.. - ?''�... ro�.:r.�r..�
.. �� ��+
•C1 ....,�,.a'!�`v rit.' •. ...� w .,'Y;,J' di y,�� � { wTt �}�`�i°��`�i-��,_;� 1
5 l y
INSPECTI ON FORM
SUBSURFACE SEWAGE.DISPOSAL SYSTEMj
�:t!' 3A .
SYSTEM INFORMAIION (continued)
Property Address: �QW 1dF0
Owner: h'
Date of Inspection: S��`qb
Depth to Groundwater �4 Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observation of Siie'(Abutting property, observation hole; basement sump etc.)
Determine it from local conditions
Check with local Board of health
Check FEMA Maps
Check pumping records
Check local excavators. installers
• Use USGS Data
Describe in your own words how you established the High Groundwater Elevation. Wust be completed)
tr;-T- Nth '
- -
(mired 0412S/97) Page 10 of 10
r?7 * t 7 y TOWN OF BARNSTABLE !
LOCATION SO �1 U t O R-04-A SEWAGE #
VILLAGE fro arts-U SL\A- ASSESSOR'S MAP&LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY 1� k000 Sam 02\ ksw
LEACHING FACILITY: (type) (size) 10t)0 2�NO.OF BEDROOMS .�
BUILDER OR OWNER
ATE: C► ._COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and 1 A 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) 1"��--� Feet
Furnished by ��),R rAL
E
0 i
3 � �
o �� J
tb� �
g.+
2 63- 32'e a �l
n 7
L 0 C`A T'16N A PERMIT NO.
VILLAG "
INSTALLER'S 4re
E i ADDRESS
R 0 OWNER
V=)a44
4,1 Lea
DATE PERMIT ISSUED _ 3- 7q
DATE COMPLIANCE ISSUED
I
���� � �--
�� Y
a��
�� 1 � ��� /
�� ` �' ,�Y
��1
V7f
No................_..: F�s....L s...............
THE COMMONWEALTH OF MASSACHUSETTS
. - BOARD OF HEALTH
t............OF...... 6dw- ...................................................
ApplirFa#ion for DhipusFal Works Tonstrnriiun 11amit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
Sy em at
± . .� 1'? 9
7"+j
_ - . ......_..._... -.. -•-- --
-L.. '. -Address 2 . or, • . -�.--,�. ....^--......7.
-•wner ..._
/ .Address.......:....................•.....
Installer Address
d Type of Building Size Lot............................Sq. feet
U
Dwelling—No. of Bedrooms____3___________________________________Expansion Attic ( ) Garbage Grinder (X )
'4 Other—T e of.Building No. of persons............................ Showers — Cafeteria
a' Other fixtures .................................
- -----------------------------------------
w Design Flow....3.. .0.............. . a4_..gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity fD a().gallons Length----.P�.......... Width._•......... Diameter................ Depth.....
x Disposal Trench—N .............._...... Width................... Total Length..__.....___. Total leaching area.._.._..........___.sq. ft.
�Q .
3 Seepage,Pit No.�!p' _ Diameter.-.��_: Depth below inlet_..._....._:..,_.Total-leaching.area. 'S._...__.sq. ft.
Z Other Dis`t'ribution box (j/)' Dosing n
'-' Percolation Test Results Performed by...... Date--;6--••-••-/= -= 7 9
a
Test Pit No. 1..... .._minutes per inch Depth of Test Pit.__.�_ __ Depth to ground water..... -4-..
Gr. Test Pit No. 2...S-?-....minutes per inch Depth of Test Pit----Z ........ Depth to ground water------
O Description of Soil.........
-' =` - -..............................................
.. . .--•••.......
x
U --•.....---••-•----•-•-------•--••---•.....................••••--------------------•.........••-•-•-----...-•--------••-•--•----••----------•-•--•-••....••--•----•-...................-•---•-•••---•---
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 TITS.;.,. 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.
/! Sig -••-•----•.................................................. ... •-•-••......•--•.....•..---
✓' Dat� s
Application Approved By--•- - �'t --................ -•Y -- -- --------X .......
(/ Date
Application Disapproved for the following reasons-..........................................................
.
•-•Date
PermitNo......................................................... Issued---••-
THE COMMONWEALTH OF MASSACHUSETTS RiB
BOARD OF HEALTH
L'J"Z�y3.._..._.....OF......,/��` �y� �
/ ..e......-----•.............................................
Appliration for Eliap.aii al Works Tonotrurtinn JIrrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
............. ._...__..v.....- -• - ......----------.-•--..................... ---------------------------••---------•...........- ---------.. .-_-----
Loca io -Address I or Lot o. r;s %
0_6 -E l� �y�.....`..........' v~'y�n1 .......�f f../) �.JC...%`—G_�:� � :'?:4y
• = ... .........
Owner Address (}
Installer Address
Type of Building Size Lot----------------------------Sq. feet
�.. Dwelling—No. of Bedrooms_-.. .....................................Expansion Attic ( ) Garbage Grinder (X )
Other—T e of Building No. .of persons............................ Showers
a YP g --------••-----•------------ P ( ) — Cafeteria ( )
Other fixtures . ---•---------- ---------------------•-----------
W Design Flow..._ ................2_S_.to-.gallons per person per day. Total daily flow----- �.._�-`.�......................gallons.
WSeptic Tank—Liquid'capacityl.l_''.12..gallons Length... Width...'!......... Diameter................ Depth..._`=!
x Disposal Trench—No..................... Width................... Total Length....._.............. Total leaching area_------------------
ft.
3 Seepage Pit No.`.`.�_:.... `Diameter../.&_�-c.. Depth below inlet................. Total leaching area.:'. _.......sq. ft.(.
Z Other Distribution box Dosing to
a Percolation Test Results � Performed bY-----•-----------•--...-•---_--------•-•-; •-----•-- -:;;---•----••----- Date.............
1----- •----------••-------
Test Pit No. 1...........:...minutes per inch Depth of Test Pit.....
......... Depth to ground water......fL
r3, Test Pit No. 2___ :.._..minutes per inch Depth of Test Pit........%....._._.. Depth to ground water........................
a' < -•------•-••----------------.—•--•--------•----.-I- ----•----.-•--------•---••-•---••-----•--------------------•---------•-•-----•---------•-----•-•---•--
O Description of Soil.................=' == =`= � r us -�.K/• ....
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 T i TLE 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...............?......................................................................
1 Date
Application Approved By..... r=����� r..... .:1--'- "`-;. -................ = --- 7.....•-----
Date
Application Disapproved for the following reasons:-----•-------------------------------•------------------•-----------------------•----------------••--............
........................•-••••...._•-••--•••.-----••-----•---•••-•-•.......-•----••-•--•••-•--•••--•-----••-•--••---------------•-••----••-•---•-----------•-•-•-------•-•------•-•--•----•-••-••.•-••--
Date
Permit'No.------•-----•--•-•-•---•••-•----•---•................... Issued_.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...............� ..........OF........... ...................................................
,; Z /' (9rrtifiratr laf Toutphatta
THIS IS TO-CERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( )
6L-
by !i(
t - :� = '` ` F ... ';... _ ` ................................................
�( 1 Installer
at...........
l j�-,ari---
G 1
has been installed in accordance with the provisions of T T r' 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No __._.._. ........ dated_.__ '_'.%r_ -__1..1�................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONS UED AS A GUARANTEE THAT THE
SYSTEM WILL FU CTI SATISFACTORY.
DATE..... ..._` ...�_1 -------•------------ Inspector_... .... -------•-----------------•---------------•---
THE COMMONWEALTH OF MASSACHUSETTS
BOARD 01 HEALTH
T
................� �� r�.a.........OF.......... „1 G!/I✓1:.... ................................................ v-
No......... �........ FEE... S...
�ta�rrr��1 nrk�,,�un��nr#Uan �erutit
Permission.is hereby granted...... --=--•--•-•
to Construct or Repair (- ) ai111ndivi'dual Sewage Disposal System/ �r
at NO.. �!!.I_C.�f__.I.L`_, C/...Z Ztir i< �.}! %k_!.-.r_..L.f. z: }fe'G. `. ,,_.� . !.� "(Z"]z_1_L,
F _. ..... ._ .. ...
Street
as shown on the application for Disposal Works Construction Per-it No�.._.__._�__}.._ Dated.._.'f _._y..........................
Board of Health
DATE........................•-•-•-----....-----•---•---•-•------
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS
- 53,00 _ TYPICAL SYSTEM PROFILE (2- Sr` �•" 5)
A R E A PLAN FDN TOP / FINISH GRADE=0 NOT TO SCALE
SCALE : I "_ �' �T fix \ , FINISH GRADE OVER TANK= 51 On FINISH I +
GRADE OVER PIT-
LO TS 1 7 � - 179 CCU I LDFORD DRIVE 30,000 S. F. -
N O T I IA I H � g� 1�,+� �J T A�� �. r 1, 0 0 i� V L i% 1 � I � I PVC OR
O O O e e .�. • • • °
4 �C. 1 . TEES '4 S �ea7 'LIS_JJ` e • e e ° e 4
qS3,�'� � 150� � ,_"1n.t�d' �--ro'�"0._'4, ` o • e . ° • • I • e ° • e
—�- B S M T —
1 l/l� ',- .' �° '-` FLR I C3 OC'` GAL. 4" i • ° ° , • • • • • 1
- ,, �-- AT T+4E BITE � � REINFORCED DIST. BOX `��'2S •
• • o • • • e e • • t
O N C R E T E 8
TO BE INSTALLED ON ° ° ' ' ' • � • ' ° ° ° '
A LEVEL STABLE BASE • ° o • • • • ° ° • e
SEPTIC TANK 2 REQ D. i ,
TO BE INSTALLED ON l`r, ;2 REQC'.� ° • • • ° ° ,
V ,� LEVEL STABLE BASE • • • • ° , ,
2"-1/8" 1/2 "WASHED PEASTONE ALL ' • • • • • ' ' • °
T , P, F-NIL).t 51 �I, P FND BRICK a MORTAR COURSES AS AROUND FREE OF IRONS, FINES • e ° e
00
REQUIRED TO BRING COVER TO GRADE AND DUST IN PLACE
` -• ..... 1 ' �� I � _. >_ 1 OG � ��
_ J � 24 "C.I . MANHOLE COVER a - 3/4 " TO 1 -112 " WASH ED CRUSHED LEACHING PIT
LOT 1 'l ( ��� 1 r ',� FRAME - SEE DETAIL STONE ALL AROUND FREE OF BASE TO BE LEVEL
--- -- I -- -- IRONS, FINES AND DUST IN
PLACE
- - -- I FOR FIN. GRADE
SEE SYSTEM PROFILE
�(k�A01 _ _ SOIL AND PERCOLATION
i .�YST �M { I I � Y jT EM 2
11
�� ��-,�..� ._�.,� .� ►,._ • I t 4 DATA
C (KtTCH E I-J 1715 p£x:,JAL_ --- -
AicC-A Ft-R AU W DQ-y I bA r)-+ '� -- 8" P E R C. RATE : ' � M I N �I N.
LC�T I0 �5I 6LvE PIT G �'� o - -� — — — --- — — -
.p. > LOT I 4 �° F
I 'l�IF�TIC, � F.}_. =7�.t�n ru --- ..... . `/ OR INV. SEE �'
BLKU INLET SYSTEM PROFILE r TAKEN BY C. D. SPOHR
k�X i�T� _1'�l�i r�. " I + LINE E a ; . . _ 6 . o o MR ;;AU J K ��.c Fes~';►�
! I 25' t J Q� IIC �E I c A car I ° J OPENINGS W i'4-1;8" WITNESSED BY. " 'kp'( BARN.
SI++ I~X I5T, !- OUTER DIA. a I -3/4 _ °
D "� DATE �U f�►=s. 1 a^ '9 r .--_�-_
#.3 SEE. Pi�FILE ': ° 3�' 1 :' 9 ,. �b '* CS �• ,s't HOL)5 7 ` . o a IN PI - ELEV.
SIDE DiA TEST T GND
�.i- A�-:XR6) r e�. I J C o� , s ,. '��` C� 6 ': . - o TOTAL c C °;
fAL.a" 5�_'±_ 'r _ -•�.. G`►viAt_ � , . 'a " o o � 3 " �' � -
70'+t:�Ipl^� ISck�I�;At- .�� � ! ' , ,•;, o p o AREA [[- _D. o o ' ,, - I YEC� � LOAt-� ti~J �U.�T, i-E�k:,>`�.
tti$k r ITN L • 0 0 0 0 C 2 T^i 0 u 0 0 ' = n , Jll Sot I� �!1 .1 .I'C
!'EECA5T �I,1CI��'C� TowN � �A +Ro►-� ruac- • - .. ��`�-_ i � . , ` o o 0 0 0 ��r��,�-4 j ° '� � � . ', � .`, `I � '.
AO WATE: R£sEtzrt , o 0 0 0 0 0 0 < gpt,1`.r G l,c,A�'e°i. _
E H tt,IG, F' T f `PA . _ 11 0 o a
SO+ -ROFI i DETAIL sEtzv F�' P t ° 4 l _ _ 0 0 0 0 7
1~�NC R� -
+ 6 '- 6 " 01A. '� I3 Z,,*-*)W I
.,G'_ Pk�CASF ���'
' Faow) 1 E14 Hit• • PtT
' SEE PkOFILE �_ 10� 6 - EFFECTIVE DIA. F hi BOT. PERC. HOLE
oQ _ , , I a .ov - - --
z lie,
.tea ---- ---- DOWN
kI P. FK . P^� _ 21 e�; �-ISET __ Si E CHIN PIT - SEC '10N
-
GIJD. � I F'. c r � ..,., NOSCALE - k'.I~_C.1 )
-
t-I E Et l`V. DESIGN DATA :
' t' II � r �" - 7' NOTE DO NOT RUN HEAVY EQUIPMENT OVER SYSTEM �
G V I L D � � � �� I ✓ =- *. �`3 ' ----.--- NO. OF BEDROOMS
~. . f � t
DISPOSAL
�
LEACHING PIT NOTES: 1 ' � '
EST. TOTAL DAILY EFFLUENT '
GALS.
�. .. _..... .,_. . . , .. I . CONC. TO BE 4000 P.S.i a 28 DAYS . SEPTIC TANK G AL.KIT-HL- N
2 . R E I N F W 6 " x 6 " 6 GA. W W. M.
I
3. 2 'AND 4 ' SECTIONS ARE AVAILABLE FOR GENERAL NOTES
GREATER DEPTH REQUIREMENTS
1 . ALL SYSTEM COMPONENTS SHALL BE INSTALLED IN
E.
M.
pp�44; [[^^ ' BUILD ;^R : ---- NOTE : • + ACCORDANCE WITH TITLE5 OF THE STATE SANITARY CODE
lam. M• I V L'T L ° EXCAVATE TO ELEV. 4(;-rl O R LOWER AS DATED JULY 1)1977 & ANY LOCAL RULES APPLICABLE.
REQUIRED TO REMOVE ALL LOAM AND CLAY CONTAINING
ALL ELEVS. 8ASED OM EXIST TC '�f CARAQ .I AP MATERIAL BENEATH PIT. REPLACE EXCAVATED MATERIAL 2 ANY CHANGE TO THIS PLAN MUST BE APPRD BY THE
GIzAD�. � I •�P• °� AEI-��'i� WITH CLEAN CLAY FREE GRAVEL MECHANICALLY BD OF HEALTH, AMC CHARLES D. SPOHR. 1
U� I � WITH COMPACTED IN PLACE. 3. WHEN CONSTRUCTION IS COMPLETED, PRIOR TO BACKFILLING,
F-LFV' + 59. 00 �( L° �� �?,, MA., c j � P � .�: `;� NOTIFY THE ENGINEER FOR INSPECTION.
j SIDE AREA = __�- S. F.Q—_S. F./GAL GALS
7 (a I ��, ; 4. FOUNDATION ELEV. MUST BE CHECKED WHEN COMPLETED.
BOTTOM AREA= S. F. - S. F./GAL - GALS TOTAL. AREA S. F TOTAL GALS
5. THESE ELEVS. MUST NOT BE CHANGED WITHOUT WRITTEN
^ �"
APPROVAL BY CHARLES D. SPOHR.
LEGEND !' ' " --' 6 FOUNDATION INSPECTION READ. WHEN EXCAVATED.
t J E RE) :
- A. ` ~ LA - $ 50.0' EXIST. GROUND ELEV.
M i2S. Vv A�L T PZ C , Sf� ICI ,
I � 0 1I D L A �! 1D v•,f,U-E� ^ REt\ �,� AM `PPEPA RF-U FRO 50.0 ' FINISH GROUND ELEV."UNCERLINEC"
t LBORO LAA . -> I UM8 T` M1LL �° CEKT�-k-Y 's i_ I. f- �75O PIPE INVERT ELEV. v DATE DESi; iP ? ! Cti
r��A � �.
SC:A�.:- 1 " - 100 2.8 MAN/ i°)"I 1 Fob. TEST PIT LOCATION SEWAGE DISPOSAL SYSTEM
-- 56 2 - 9 �546 C150s.) PETEQ, 5" FA F F F-R- BY 8AR.W
� O SEPTIC TANK � � FOR
�0M 5U L'rAMT,5 P� K �q 7 PG �� L-� M Ivy . , T E Mk. � � � S. �� L R C. BRENNAN
AWD PLAKI, P5!c 25 /4'- P'"' , 3 2 ❑ DISFRIBUTION BOX !_-_7.�_ t �^}[; _,-
4 " C. I PIPE I l 9 -GU I LD1^ ORD _D�-�-_
- I NER IE" CE(`JTEkV I LLE I MA.
t-ttt-ttttt- 4"BIT. FIBER PIPE TIGHT- JOINTS N TS LC
�.T '<, � ..-__ ' _
- -
t DESIGNED: C.D-SPOHR DATEj.-6 APle. 79
PROPERTY LINE DRAWING - NO �
— -.- -_-
�.
DRAWN: SCALE.ASSHOWN
� MIN, CCCE DISTANCE I L
E P _-t— —�.—U+T C H E',K E D: C. D S .