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HomeMy WebLinkAbout0050 HOLLY HILL ROAD - Health 5-D HOLLY HILL RD. I CENTERN MAP-PARC. 188-101 14 Y7 r 4� No. 42101/3 ORA ESSELTE 10% (* o a o a Commonwealth of Massachusetts Title 5 Official Inspection Form ', " n Subsurface Sewage Disposal System Form-Not for Voluntary Assessmentsr GM , 50 HOLLY HILL RD "' Property Address MARIE ETCHELLS Owner Owner's Name information is required for CENTERVILLE MA /-4,02632 2-5-1 5' � every page. City/Town' r' State f, Zip Code Date of Inspection C.S Inspection results must be submitted on this form. Inspection forms may not,be altered in any way. Please see completeness checklist at the end of the form. ti Impo When filling out A. GeneM1raI Information .�,nt: �S/ /l�f2 2. forms on the computer,use 1. Inspector: only the tab key y.. to move your DOUGLAS A BROWN cursor-do not use the return Name of Inspector = key. D.A.BROWN INC �I Company Name . P.O. BOX 145 Company Address CENTERVILLE MA 02632 'e°0f1 City/Town State Zip Code 508-420-4534 S14297 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 - 2-5-16 Inspector' ignature 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 System•Pagel1 of 17 L __ m - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 5 50 HOLLY HILL RD Property Address MARIE ETCHELLS Owner Owner's Name information is required for CENTERVILLE MA 02632 2-5-16 every page. Cityrrown 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: AT TIME OF INSPECTION SYSTEM MET ALL PASSING REQUIREMENTS. PROPERTY IS. CURRENTLY OCCUPIED BY ONE PERSON. FUTURE PERFORMANCE UNDER THE SAME OR INCREASED USE CAN NOT BE DETERMINED 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): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 50 HOLLY HILL RD Property Address MARIE ETCHELLS Owner Owner's Name information is required for CENTERVILLE MA 02632 2-5-16 every page. Cityrrown 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•3113 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 50 HOLLY HILL RD Property Address MARIE ETCHELLS Owner Owner's Name information is required for CENTERVILLE MA 02632 2-5-16 every page. City/Town 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 asses if the well water analysis, performed y p y , 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 '/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 50 HOLLY HILL RD Property Address MARIE ETCHELLS Owner Owner's Name information is required for CENTERVILLE. MA 02632 2-5-16 every page. Citylrown 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. ❑ ® 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 Y rY 9 Pp Y ❑ ❑ 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 50 HOLLY HILL RD Property Address MARIE ETCHELLS Owner Owner's Name information is required for CENTERVILLE MA 02632 2-5-16 every 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 50 HOLLY HILL RD Property Address MARIE ETCHELLS Owner Owner's Name information is required for CENTERVILLE MA 02632 2-5-16 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: AS PER AS-BUILT CARD SYSTEM CONSISTS OF A 1500 GALLON TANK D-BOX AND A S.A.S. CONSISTING OF INFILTRATORS. Number of current residents: 1 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 years usage (gpd)): Detail: 2014----180 2015---176GPD SYSTEM IS NOT DESIGNED FOR A GARBAGE DISPOSAL 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 50 HOLLY HILL RD Property Address MARIE ETCHELLS Owner Owner's Name information is required for CENTERVILLE MA 02632 2-5-16 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: CURRENTLY OCCUPIED Date Other(describe below): General Information Pumping Records: Source of information: OWNER Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? TANK TRUCK Reason for pumping: MAINTENANCE 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): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °wM 50 HOLLY HILL RD Property Address MARIE ETCHELLS Owner Owner's Name information is required for CENTERVILLE MA 02632 2-5-16 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 9-12-97 PER AS-BUILT Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 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.): Septic Tank(locate on site plan): Depth below grade: 1.75 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 GALLON Sludge depth: MODERATE t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 50 HOLLY HILL RD Property Address MARIE ETCHELLS Owner Owner's Name information is required for CENTERVILLE MA 02632 2-5-16 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 Scum thickness MODERATE Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? WOODEN POLE Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): TANK WAS PUMPED FOR MAINTENANCE AT TIME OF INSPECTION. IT HADENT BEEN DONE IN SEVERAL YEARS. RECOMMEND RISERS TO BRING COVERS CLOSER TO GRADE. ALSO THERE IS A IRRIGATION LINE THAT RUNS OVER ONE OF THE COVERS RECOMMEND RE ROUTING IT. 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 50 HOLLY HILL RD Property Address MARIE ETCHELLS Owner Owner's Name information is required for CENTERVILLE MA 02632 2-5-16 every 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4M , 50 HOLLY HILL RD Property Address MARIE ETCHELLS Owner Owner's Name information is required for CENTERVILLE MA 02632 2-5-16 every 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 0" Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): BOX LEVEL NO LEAKAGE RECOMMEND INSTALLING A RISER TO BRING COVER CLOSER TO GRADE 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: NO OBSERVATION PORTS WERE PRESENT t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 50 HOLLY HILL RD Property Address MARIE ETCHELLS Owner Owner's Name information is required for CENTERVILLE MA 02632 2-5-16 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: TRENCH ® leaching chambers number: INFILTRATORS I ❑ 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.): 40X6.83 TRENCH OF INFILTRATORS. NO OBSERVATION PORTS PRESENT. LEVEL OF PONDING COULD NOT BE DETERMINED. THERE WERE NO SIGNS OF FAILURE IN THE AREA OF S.A.S 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 50 HOLLY HILL RD Property Address MARIE ETCHELLS Owner Owner's Name information is required for CENTERVILLE MA 02632 2-5-16 every page. Cityrrown 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.): I, t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments GSM , 50 HOLLY HILL RD Property Address MARIE ETCHELLS Owner Owner's Name information is required for CENTERVILLE MA 02632 2-5-16 every page. City/Town 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M 50 HOLLY HILL RD Property Address MARIE ETCHELLS Owner Owner's Name information is required for CENTERVILLE MA 02632 2-5-16 every page. Cityrrown. 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: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: 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 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 50 HOLLY HILL RD Property Address MARIE ETCHELLS Owner Owner's Name information is required for CENTERVILLE MA 02632 2-5-16 every page. Citylrown 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 tr TOWN OF-BA.RNSTABLE LOCATION au^2' +yllL RLi9 5$WAr, VILLAGE CrJ�I�`f/,I1ALC i �- ASSESSOR'S MAP&LOT 1 uj INSTA4LER'S NAMB&PHONE&O.Alld Q44L_ SEPTIC TANK CAPACITY LEAD-ENO FA :TPY: (t,paj �i� f{ j e s (Bile) C �X G.83 No.or OBI)ROOMS f BUILDER OR OVMR:-A,-a"Af .rl r •S ¢� Q j FBRMIMAT8: -COMPLIANCE DATE: _. . Separation Distance Between tbe: Mwdmum Adjusted,amundwater Table and Bottom of Lcachiug FaciUty peat Priests Waf ,Svpply W�1 sold-Leac ,I~»�:Iity (If any welts exist k�p+S on site or"within 290 feet of leachsa' fadility) jet Edge of Wetland,andjeachtgTictllt if:any wetlands ezlss within 300 fcet of loathing fa }ci$ ��' wt .'• Est Fumishod by I I c- _ � ALt4fl 7� '70 I t',q tiwe 4 tt j ,�a r� '/TOWN OF BARNSTABLE ° LOCATION �O yDLd y 111M 12M P SEWAGE# VILLAGE 65,gY'f21114 /114 ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NOARlIE: SEPTIC TANK CAPACITY LEACHING FACILITY: (type) 7~l1f/S�h� /NAX7447AS (size) VOX �-83 NO.OF BEDROOMS 3 - BUILDER OR OWNER "£�GM/4oy 420I-ff',Ck S PERMITDATE: f 1-31 -/6 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility ? - Feet Private Water Supply Well and Leaching Facility (If any wells exist ti� w4l/S on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist Nv we . within 300 feet of leaching facility) Feet Furnished by A, r 2 34'G L4 tyem Gt ,� 0 ®C 3 c y vt6_7 4 , No. , ..1 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS AppItration for ;W5pool *p$tem Comaruction Vermtt Application is hereby made for a Permit to Construct( )or Repair( )an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. �v-r 4vw je 4) ,- lIA• E czt S Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow nJ 3.0 gallons per day. Calculated daily flow y gallons. Plan Date 111—to•-4 to Number of sheets ( Revision Date 64 //A- Title6Iri i-- Se Pi�,_Ac . Df__wDi C+:1 AAVwI-! Phw _ dW/ Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued y t 4s Board o ealth. Signed A Date Jz �/ Q Application Approved by Application Disapproved for the following reasoy— �6Permit No. Date Issued z�h,11--,Z4,11? TOWN OF BARNSTABLE 9 SEWAGE# LOCATION o,you y y 'VII.LAGE �'� l�iU ASSESSOR'S MAP &LOT 1� INSTALLER'S NAME&PHONE NO. O SEPTIC TANK CAPACITY LEACHING FACILrN: (type) lNx/Lr/L97 S (size) ::NO.OF BEDROOMS 3 `BUILDER OR OWNER £�G/H/4 `PERMIT DATE: COMPLIANCE DATE: 9 Separation Distance Between the: ?7 7 Feet Maxim rn Adjusted Groundwater Table and Bottom of Leaching Facility private Water Supply Well and Leaching Facility (If any wells exist No (041-5 Feet on site or within 200 feet of leaching facility)Edge of Wetland and Leaching Facility(If any wetlands exist Nv wc')L Feet within 300 feet of leaching facility) Furnished by ' h . Z �hrrl cj .i� � � � . Q -Vh S 1 01. S1. �7 b bh y-ah Lb aI b Lfi '.67� z 1 61 41 l 41 ,F'� ..~ ,.. .�."�T't. :r� r^+ '- r +."..,+,-^ - .'!, 3-... r ..�i+.+ O'.-4.i•:6 ,..:,^+. .,� `+.:.�. ....s*^.='"• ..�. .. � . r:{". r!i ra _ �y i`'•;-�.,..,i, Gay � M� No. ..__ . I ll./ I —�#� Fee a -------�f? THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN.OF BARNSTABLE., MASSACHUSETTS 2pprication for Digozal �&pgtem onotruction Permit Application is hereby made,for a Permit to Construct( )or Repair( )an On-site Sewage Disposal System at: Location Address or Lot No. Owner's.Name,Address and Tel.No. WT- At-1 �6u� 1- ►.i 4__� GEC a �'�'.• ,..� 144 . Installer's Name,Address,and Tel.No. . Designer's Name,Address and Tel.No. " ® OFA+G Type of Building: Dwelling No.of Bedrooms 3 Garbage Grinder( ) Other Type of Building ' No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow ".I 3,O gallons per day. Calculated daily flow 77`7 y• gallons. Plan Date ( Y-W ._y Z. Number of sheets (_ Revision Date 64 /A Title[, i m + Se .a 3 K.-r_ Pfi&7.h or- WT"-,-+:l t4y""w 1± 1, 2ta 64,0tv'ZZt/s Description of Soil j Nature of Repairs or Alterations(Answer when applicable) 1 Datellast inspected: Agreement: The undersigned agrees to ensure the construction'and maintenance of the'afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- Cate of Compliance has been issued by t 's Board o ealth. Signed ;41V_c_ + Date Z / Application Approved by Application Disapproved for the following reas Permit No. Date Issued __________--=_-- ——— {{� THE COMMONWEALTH OF MASSACHUSETTS /. PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS , Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repairedireplaced( )on by as .a►_ for ' as tJ h;Tconstructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No ated Use of this system is conditioned on compliance with the provisions set forth bel w: Y "No: _. Fee A THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Aigo.5aY *pgtem* Con.5truction Permit ' Permission is h by granted to to construct( repair -_)a O jite Se .age System located at and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title�5 and the following local provisions or special conditions. All construction must be co plete within two years of the date below. G Date: Approved bye o / 's T.O.F. AT EL SEPTIC PROFILETEST HOLE LOGS I (NOT TO SCALE) if ACCESS COVER TO WITHIN fr OF FIN. GRADE ACCESS COVER (WATERTIGHT) TO ENGINEER: -41.,,SjMINIMUM .75' Of' COVER OVER PRECAST WITHIN S' OF FIN. GRADE 2% SLOPE REQUIRED OVER SYSTEM _L 4 `�gv -'> WITNESS: � 1-`., I It ob RUN PIPE LEVFL I _ ;# FOR FIRST 2' e�� '7 1-0 ili DATE: 2 (DI3-=-) PROPOSED GALLON S,Epnc PERC. RATE 12 TANK (H .2!51 CLASS SOILS P#CYR SLOPE) 6- CRUSHED STONE OR MECHANICAL DEPTH OF FLOW COMPACTION. (15.221 (21) a TEE SIZES: SLOPE) (-' X SLOPE) T INLET DEPTH OUTLET DEPTH LOCATION MAP ASSESSORS MAP PARCEL FOUNDATION— SEPTIC TANK 7-" D' BOX LEACHINGFACILITY FLOOD ZONE Ink a,1-44 BUILDING ZONE:_.__e- ,4- SETBACKS: FRONT - SIDE - �� \ i✓p,.r (�� Lt4..� �J �. REAR - P[_AN REFERENCE: -7 f 4.� 4� A.0 NOTES: 1 . DATUM IS 2. MUNICIPAL WATER IS SEPTIC DESIGN: (GARaAGE r)ISFIOSER IS f-42Z PER FOOT. 3. MINIMUM PIPE PITCH TO BE 1/8 DESIGN FLOW: BEDROOMS ( '_­2 GPD) "��IOGPD 4. DESIGN LOADING FOR ALL PRECAST UNITS TO BE AASHO-H_��L_,__ GPD DESIGN FLOW USE A !� -TIC TANK: GPP -- -,GALLONS S. PIPE JOINTS TO BE MADE WATERTIGHT, _SEI-_ 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH MASS, A, 4k 1,.. USE7 CALLON SEPTIC TANK ENVIRONMENTAL CODE TITLE V.� ; '- � _ '�\ ""� pi? 7. THIS PLAN !S FOR PROPOSED WORK ONLY AND NOT TO BE USED FOR LOT LINE STAKING, G P D LEACHING: 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40--4" PVC. BO7OM: p 2 4 G pr) - 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED WITHOUTTOTAL: ��l S.F. 0 GPD INSPECTION BY BOARD OF HEALTH AND PERMISSION OBTAINED `- , 1- �` FROM BOARD OF HEALTH. le-IL, 000 \/G--Q_� r- ,, 5 v �T -.I_i-, ">c AfLv.4 cllp_ T2zopo'ST__o L A C r- t_Y o N S Tyz C-r 90 SITE AND SEWAGE PLAN OF 4 4 qv IN THE TOWN OF: BOARD OF HEALTH /K C1 MA PREPARED FOR: . I � �- 0�4� APPROVED DATE _ 1 Feet Ic/ SCAJY, DATE: down cipe en 'neering, CIVIL 'NGINEFR!:�` P, LAND StTRVEYORS 04WA 'A PHONE 508--362--454' L FAX 508--362-9880 JOB main st. yarmouth, ma # J. AOJA DATE 4, t. SEPTIC PROFILE TEST HOLE LOGS T.O.F. AT EL 4 .o NOT TO SCALE) tr ACCESS COVER TO WITHIN a OF FIN. GRADE Y • � AccEss COVER (wATtirarIGHT) To ENGINEER: - WITHIN 6' OF FIN. GRADE �$Z S MINIMUM .75' OF COVER OVER PRECAST 27C SLOPE REQUIRED OVER SYSTEM .—' rC .� WITNESS: __ ..__�_____s1� .—_.may._ ' � ..._ \``�' •,'� ,� � Y RUN PIPE LEVEL -.s�.l-a7,S'r✓,.yE •:rya,. DATE .:::'• ' " - r '''. (D�=) FOR FlRST 2' ,/� 1� V iPOSED I i , _ 1 rp GALLON SEPTIC I �9 �, PERC. RATE qo. 4 TANK (H L.) CLASS _ SOILS P# (_1X SLOPE) �_6' CRUSHED STONE OR MECHANICALJ4 r I �y �O`'rS" '. �`w:` "'` DEPTH OF FLOW COMPACTION. (15.221 [21) rV ( ] TEE SIZES: (�X SLOPE) (1 X SLOPE) 4s $ Cr INLET DEPTH OUTLET DEPTH = �•� I S � � a � � � LOCATION—MAP 1' • Z — ASSESSORS MAP �.' '` PARCEL FOUNDATION— I SEPTIC TANK -- --- I 1 ------ D' BOX ---- — LEACHING ,� �1' FACILITY FLOOD ZONE BUILDING ZONE: �-lorE �,Nv'��;f � � SETBACKS: FRONT - ,V,,. a• ;�., SIDE L,-( o P �.� REAR - 1 r� •' ;yet � {f ie+!'i L V 1"'V'► `0�,�^+•eti.(y'i7 \t PLAN REFERENCE: .� L"! 0" f _ . NOTES: (�+2"'-• ...'� ....._. ...-. � 1. DATUM IS r1 SEPTIC LEStGN: (GARBAGE DISjDOSER IS _.4� ► ) 2. MUNICIPAL WATER IS — MINIMUti! PIPE QITCH TO BE 1/8" PER F()OT. DESIGN FLOW: BEDROOMS (-1� GPD) = ��9 GPD �� — 4. DESIGN LOADING FOR ALL PRECAST UNITS TO BE AASHO USE A GPD DESIGN FLOW 5. PIPE JOINTS TO BE MADE WATERTIGHT. SEPTIC TANK: GPD (_ ) _ ��a,7GALLONS 1 ' " •., -- 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH MASS. �; �• w ',ate r"``` �, USE A t=�_�GALLON SEPTIC TANK ENVIRONMENTAL CODE TITLE V. LEACI�iIi+IG: 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT TO BE b�� • , — I±IN -- USED FOR LOT LINE STAKING. Q. h \ ,.., SIDE`. : Z <10 7-5 s i l lF ) = i'" ' .. ri a __1_________�_ (_:.__. GPD 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4 PVC. BOTTOM: 40. $3 ( -74 4 GPD � -- 9.. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED WITHOUT TOTAL: �j S.F. ?4� J' GPD INSPECTION BY BOARD OF HEALTH AND PERMISSION OBTAINED FROM BOARD OF HEALTH. G , e:. "., �b0 ar`Pa j F-+t tii i. bil t^r t' fr. i� L "Ct�' A ©N 5 T'y� v c_T t 0,N 2 `O © o V—� /r2G •` ` �— � � N ov +was SITE AND SEWAGE PLAN OF M _IN THE TOWN OF: / �r HOARD OF HEALTH M. t��'4 ,.•• ;;:.. PREPARED FOR: ' "� APPROVED DATE MA PRARE v6 , ` _ C =t r.. Foot ,l f . a -- / SCALE: DATE: ,� l ,�.- �,,�- ---- !n ' '4 - down cape engineering, Inc. 'Vv r �� .. _ ,. ,.... , �,r,iT�� :; CIVIL ENGINEERS +ft*iK. �" -- v� LAND SURVEYORS rA PHONE 508-362-4541 % FAX 508-362-9880 .. } JAB# ,� �� . 93±a main st. yarmouth, ma ,, jA - i .t .s. DATE