HomeMy WebLinkAbout0491 HUCKINS NECK ROAD - Health 491 Huckins Neck Road
A= 233-071
Centerville
eS ?
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
491 Huckins Neck Rd.
Property Address
Donald Summers
Owner Owner's Name
information is required for Centerville Ma. 02632 5/1/2009
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important: A. General Information
When filling out
forms on the
computer, use 1. Inspector:
only the tab key
to move your Robert Paolini
cursor-do not Name of Inspector
use the return
key. Capewide Enterprises,LLC.
Company Name
r� P.O.Box 763
Company Address
Centerville Ma. 02632
re1� City/Town State Zip Code
(508)428-4028 S14454
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 ❑ F�ls' � y .
»� t
❑ Needs Further Evaluation by the Local Approving Authority =�
03
5/1/2009 s- T"
Inspector's Sig-niluV 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
s
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 491 Huckins Neck Rd.
Property Address
Donald Summers
Owner Owner's Name
information is required for Centerville Ma. 02632 5/1/2009
every 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:
The septic system is in proper working order at the present time.
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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
f
t
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 491 Huckins Neck Rd.
Property Address
Donald Summers
Owner Owner's Name
information is required for Centerville Ma. 02632 5/1/2009
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
r
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 491 Huckins Neck Rd.
Property Address
Donald Summers
Owner Owner's Name
information is required for Centerville Ma. 02632 5/1/2009
every 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 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
y
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
491 Huckins Neck Rd.
Property Address
Donald Summers
Owner Owner's Name
information is required for Centerville Ma. 02632 5/1/2009
every 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.
❑ ® 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
❑ ❑ 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-09/08 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
^M 491 Huckins Neck Rd.
Property Address
Donald Summers
Owner Owner's Name
information is Centerville Ma. 02632 5/1/2009
required for '
every page. Cityrrown 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): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
° M 491 Huckins Neck Rd.
Property Address
.Donald Summers
Owner Owner's Name
information is required for Centerville Ma. 02632 5/1/2009
every page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
The septic system consists of a 1000 gallon septic tank,distribution box and three flowdiffusers.
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ® Yes ❑ No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available last 2 ears usage 2007:36,000
g ( Y g (gpd))' 2008:24,000
Detail:
2007:99 gpd. 2008:66 gpd.
Sump pump? ❑ Yes ® No
Last date of occupancy: 5/1/2009
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-09/08 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
°M 491 Huckins Neck Rd.
Property Address
Donald Summers
Owner Owner's Name
information is required for Centerville Ma. 02632 5/1/2009
every page. Cityrrown 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: Capewide Enterprises,LLC.
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping: Last Pump 4/8/08 for 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 491 Huckins Neck Rd.
Property Address
Donald Summers
Owner Owner's Name
information is required for Centerville Ma. 02632 5/1/2009
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
1986
Were sewage odors detected when arriving at the site? ❑.Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 9.5
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: 10+
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Joints appear tight.No evidence of Ieakage.System vented through the house vents.
•
Septic Tank (locate on site plan):
Depth below grade: 8.5'
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:
1000 gallon H2O
Sludge depth:
1"
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 491 Huckins Neck Rd.
Property Address
Donald Summers
Owner Owner's Name
information is required for Centerville Ma. 02632 5/1/2009
every page. City/Town 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
31"
Scum thickness 0
11
Distance from top of scum to top of outlet tee or baffle
81'
Distance from bottom of scum to bottom of outlet tee or baffle
14"
How were dimensions determined? Measured
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pump septic tank every two years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank
appears to be structurally sound.
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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
491 Huckins Neck Rd.
Property Address
Donald Summers
Owner Owner's Name
information is required for Centerville Ma. 02632 5/1/2009
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
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•09/08 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
;M 491 Huckins Neck Rd.
Property Address
Donald Summers
Owner Owner's Name
information is required for Centerville Ma. 02632 5/1/2009
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
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.):
Unable to expose D-Box under asphalt driveway.
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.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
L
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 491 Huckins Neck Rd.
Property Address
Donald Summers
Owner Owner's Name
information is required for Centerville Ma. 02632 5/1/2009
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 3-Flowdiffusers
❑ 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.):
Sandy dry soil.No signs of hydraulic failure.Leaching was dry at time of inspection.
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•09/08 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
491 Huckins Neck Rd.
Property Address
Donald Summers
Owner Owner's Name
information is required for Centerville Ma. 02632 5/1/2009
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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of W
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Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
;M 491 Huckins Neck Rd.
Property Address
Donald Summers
Owner Owner's Name
information is Centerville Ma. 02632 5/1/2009
required for
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
❑ Shallow wells
Estimated depth to high ground water: Bottom of leaching 6.9'
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:
As-Built Card
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
USED:USGS Observation Well Data. USED:Technical Bulletin 92-0001 Plate#2 annual ranges of
groundwater elevations.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M D491 Huckins Neck Rd.
Property Address
Donald Summers
Owner Owner's Name
information is required for Centerville Ma. 02632 5/1/2009
every page. Cityfrown 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
l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
ASSESS( .S MAP,N0: 33
PARCEL NO.: 1 2/
THE COMMONWEALTH OF MASSACHUSETTS
.BOARD OF HEALTH
............. ...:... ....................OF......................................--- ..........................................
Appliration for Bi-spuiittl Works Tonstrur#ion Vantit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
....:...........__.----r.................---.-------- �----------..................---- ... -�---------_......... -----
Location Addre' or Lot No.
- .. ..... .•-- ------------- �..._......._.........
- Owner Address
Installer l Additess
d Type of Building Size Lot_�53?d!;;�....Sq. feet
aDwelling—No. of Bedrooms.__..._________________________________Expansion Attic ( Garbage Grinder Ab
p, Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures .---•-•-•-----•--------•------------------------------ --•--------•--•--•--------------•--•--•-•-----•------------•-•-----•--.......---....---_-----
d -
W Design Flow______.���r__________________________gallons per person Yer dpy. Total daily flow......... :3_!0....................gallons.
WSeptic Tank—Liquid capacity_.1allons Length Width_4_`ld____ Diameter_______ _____
x Disposal Trench— ........... Width.......AD....... Total Length......73Q____ Total leaching area.._ _(�;)_...sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box Mal. Dosing tank (
Percolation Test Results Performed bye:S'C �___ _Y__ ___________________ Date... _lam_-__-.
Test Pit No. 1----- --------minutes per inch Depth of Test Pit-----1 Le ... Depth to ground water_._ E�_- ��cs�
(i Test Pit No. 2...... ........minutes per inch Depth of Test Pit......1!~J....... Depth to ground water. ...................
a --•-------------------------------••-------------------------------...•-------•---------....._....__.........................................................
0 Description of Soil_.!. �...!!Yt..
x
c, ------------------------------------------------
W .... ......... ____.____.____.___.__._.___._.._.____._.____._.._...______.-_"_. _]:___._.___._.____..___..._.__._______..._..____._________ _______
UNature Repairs or Alterat l�s—A sw r when applicable_,_:' 1. 1_)z �.. ........:. - _.__ ..._...
.............. ---------------
Agreement: t^ (^ -� c::r �� e-N
The undersigned ees t install the 'aforedescribed Individual-Sewage Disposal System in accordance with
the provisions of TIT 5 of he State Sanitary Code—.The undersigned further agrees not to place the system in
operati it a tifi to Compliance has been ed by the board o alth;
vv" Dafe
Applica on Approved BY----------------•------------• .!........•. --•------•-----• ----• .
Date
Application Disapproved for the following reasons________________•_-____-_________....._____________..__...__________________________________.....______-_-______
--•..........................•---.....---•---------------------•----••-----•----..._...---•-•---------------....---•------------------------------------------------------------------------•-----------
Date
Permit No....... 2 i - Issued.......................................................
Date
................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.................. ........................OF....................
Appliration for Disposal Works Tonstrurtion Prruat
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at:
r .....aj ................................... .
............. ""�'K'07*----------
=6 •Addr��j... K,
............... ............... 4
Adq se
,la� �4 . . ........................... •1.4 67k;tal'I'er Address
U Type of Bu Dwelling ......ilding 3—No. of Bedroonis.., �,,Size Lot............................Sq. feet
...........Expansion Attic Garbage Grinder (1,
AW Other—Type of Building ............................ No. of persons............................ Showers Cafeteria
Other fixtures ........................
---------------------------------------------*......*----------------------------".........
Design Flow.._.....:?..t�-�..........................gallons gallons per person per O�y. Total daily Pow........a ...................gallons.
Septic Tank—Liquid*capacity__ Length.&�'G..... Width.A-.10.... Diameter..... Depth...
Disposal Trench—No.------A........... Width........1.0....... Total Length...__..: ... Total leaching area.-',)EA.C1...sq. ft.
Seepage Pit No..................... Diameter....................
Depth inlet.._..._............. Total leaching area..................sq. ft,
z Other Distribution box Performed byA�4 K Dosing-;ank o
r-I
.
Percolation Test Results ................U��f-11-AC................... Date...
Test Pit No. I................minutes per inch Depth of Test Pit..._......._..__.... Depth to ground water... ...... t L v
...
41 Test Pit No. 2................minutes per inch Depth of Test Pit._..!.L-a........ Depth to ground water......`."........`.....
9 � ........................... ....... ...........................;
— .........:�..........��'4zz..........
0 Soil. --------',�
. ...........
Description of So ... ...... ....e4tz�...............�0... L
--- ------------- -- ........
-------------------------------"------------------------------"------------**-------------- --------------**-------"------------------------------------------"-------
...................................................................................................................... .. ....... . . .... ..... �%.�.....
u e epa, — IT&"A � #,9 , .
Nat f airs or Alter A en ap&,ca __ .. ---I*i
............
..............................................
r I------
U
in Agreement:
The undersigned IT ed agee'eso install the aforedescribed Individual Sewage Disposal System,in accordance with
the provisions of'I 5 of 'the State Sanitary Code—.The undersigned further agrees not to place the system in
ope ati u, t R a e/rt i to ovCompliance has, been 1 ed by the board of health.
Signed . ..................
Date.
Applic'a ion Approved By.... ....... ... ..........
.............
t's1b al.
Application Disapproved for the following reasons:...........................................................................................................---
........................................... ...........................:.....................................................7------------------------ ---------------------
Z.1'2 1 Date
PermitNo--------------------- .......... Issued........._...... .---.........•---•..............
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
. OF.......... -OE..........................
"Vrrfifirate
.........
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired
by. . � Installer er
1..........."......... ............................. ........ .. .
at.............. .... . ....... � 6 nLu11 .............................. .
has been installed in accordance with the provisions of TITIZE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No_____________ z;?...... dated---------� ............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANI THAT THE
SYSTEM WILL FUNCTIO SATISFACTORY.
DATE................... . .................................. Inspector...................................................................................
—THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
No......................... ..........................................OF...... . ....... . . ............... ..................................
13isposallgorks Tonstrwtion ramit
......................................................... ........ ...
Permission is hereby granted...........
to Co*nstr (:�,of Repair.
q An Indivi Se e D osal Sy
U - ....V I oc=�, #.J -
ato.............. .....I...I..... . . ....
Street
as shown on the application for Disposal Works Construction Permit ...ebated...... .__-' .... .....
.. . ........... ..................................
I2,R - Board of ralth
DATE---------------------.....C......................................................
FORM 1255 A. M. SULKIN, INC., BOSTON
BAXTER & NYE, INC.
Registered Land Surveyors and Civil Engineers
7 Parker Road/Osterville,Massachusetts 02655/Tel. (617)428-9131
WILLIAM C.NYE,R.L.S.-President
RICHARD A.BAXTER,R.L.S.-Vice President PETER SULLIVAN,P.E.-Vice President-Engineering
July 1.0, 1986
Board of Health
P.O. Box 534
Hyannis, MA 02601
RE: Lot 71 Huckins Neck
Road, Centerville
Dear Board:
In accordance with. your request I, have provided
on site supervision for the installation of� the ' septic
system at Lot 71 .
In brief •the system has been installed. as per the
approved plan.
I trust this meets your present needs .
Very truly yours,
Peter Sullivan, P.E.
Baxter & Nye, INc.
CC: Gary Blazis
jA OF
PS/cas a,�P� Mgss9
Pr.TER
SULLIVAN v
NO. 29733
• Apa..���lsr�a� �ti�
FSStONAL
MEMBERS OF
CAPE COD SOCIETY OF PROFESSIONAL ENGINEERS AND LAND SURVEYORS/AMERICAN CONGRESS ON SURVEYING AND MAPPING
MASSACHUSETfS ASSOCIATION OF LAND SURVEYORS AND CIVIL ENGINEERS
oaf i�
BAXTER & NYE, INC.
Registered Land Surveyors and Civil Engineers
7 Parker Road/Osterville,Massachusetts 02655/Tel. (617)428-9131
WU11AM C.NYE,R.L.S.-President
RICHARD A.BAXTER,R.L.S.-Vice President PETER SULLIVAN,P.E.-Vice President-Engineering
May 9 , 1986
Mr . Gary Blazis
531 Lumberts Mill Road
Centerville, MA 02632
Re: Lot 4 - Huckins Neck Road
Dear Mr . Blazis:
This is to inform you that on May 8 , 1986 a test
hole was dug on the subject lot.
Based upon present regulations, the test showed that
the soil is acceptable to evelation 34 , 5 for the installation
of a subsurface sewage disposal system.
The design plan will be updated to reflect the additional
test hole.
Very truly yours,
Peter Sullivan, P.E.
Baxter and Nye, Inc.
PS/fmj
OF
V
PETER
v SULLIVnN
No. 297 33
ass/ONA L Ex"
MEMBERS OF
CAPE COD SOCIETY OF PROFESSIONAL ENGINEERS AND LAND SURVEYORS I AMERICAN CONGRESS ON SURVEYING AND MAPPING
MASSACHUSETTS ASSOCIATION OF LAND SURVEYORS AND CIVIL ENGINEERS
ASSESSOR'S "MAP NO. :2- 3,3 PARCEL 0 7
LOCATION SEWAGE PERMIT NO.
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VILLAGE
INSTA LLER'S NAME i ADDRESS
cS' C7D Y 4-:PdZ 12< Jv A
S UILDE R OR OWNER
DATE PERMIT ISSUED /
DATE COMPLIANCE ISSUED -�
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