HomeMy WebLinkAbout0084 LIAM LANE - Health 84 LIAM LANE, CENTERVILLE
A= 167 016.014 `
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Commonwealth of Massachusetts
.� Title 5 Official Inspection Form
it Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
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84 Liam Ln
Property Address «n�
Brenda Willis f ,
Owner Owner's Name
information is required for every Centerville MA 02632 3-17-20
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.
A. Inspector Information 51# /qilf � .
Shawn Mcelroy
Name of Inspector
Wiper Cape Septic Services
Company Name
P.O. Box 73
Company Address
E. Falmouth MA 02536
City/Town State Zip Code
1-508-495-0905 S13971
Telephone Number License Number
B. Certification
I certify that:l am a DEP approved system inspector in full compliance with Section 16.340 of Title 5
(310 CMR 15.000);I have personally inspected the sewage disposal system at theproperty address listed
above;the information reported below is true, accurate and complete as of the time of my inspection; and
the inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that
the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
3-17-20
nspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system 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 form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: 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.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
Commonwiealth,of'Massachusetts '
Title 5 Official Inspection Form
t Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
� .. ,> 84 Liam Ln
Property Address
Brenda Willis
Owner Owner's Name
information is required for every Centerville MA 02632 3-17-20
'
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System,Passes: .
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
System is in good working order with no sign of failure.
2) 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):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
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Commonwealth of Massachusetts
qji Title 5 Official Inspection Form
hI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
>" 84 Liam Ln
Property Address
Brenda Willis
Owner Owner's Name
information is required for every Centerville MA 02632 3-17-20
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ 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 El ❑ ND (Explain below):
❑ obstruction is removed ❑ Y El ❑ 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 El ❑ ND (Explain below):
❑ obstruction is removed ❑Y ❑N ❑ ND (Explain below):
3) 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.
a. 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:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18
c Commonwealth of Massachusetts
�r
Title 5 Official Inspection Form
�I�i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
84 Liam Ln
Property Address
Brenda Willis
Owner Owner's Name
information is required for every Centerville MA 02632 3-17-20
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ 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
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioningin a manner that protects the public health,
safety and environment:
❑The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface.water supply.
❑The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) 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 systems 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
tsinsp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18
Commonwealth of Massachusetts
f� Title 5 Official Inspection Form
a) Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
84 Liam Ln
Property Address
Brenda Willis
Owner Owner's Name
information is required for every Centerville MA 02632 3-17-20
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® 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 'h day flow
® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
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 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determiried 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.
5) 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 CA.
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
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18
Commonwealth of Massachusetts
ot, Title 5 Official Inspection Form
i�► Subsurface Sewage Disposal System Form Not for Voluntary Assessments
84 Liam Ln
Property Address
Brenda Willis
Owner Owner's Name
information is required for every Centerville MA 02632 3-17-20
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes"to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate "yes" or"no"for each of the following for all inspections:
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?
® ❑ Wasthe 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)]
r
t5insp.doc•rev.712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
i",l w_� Subsurface Sewage Disposal System Form -'Not for Voluntary Assessments
r U ;
84 Liam Ln
Property Address
Brenda Willis
Owner Owner's Name
information is required for every Centerville MA 02632 3-17-20
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): N/A Number of bedrooms (actual): 3
DESIGN flowbased on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): N/A
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
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:
Sump pump? ❑ Yes ® No
Last date of occupancy: 2019
Date
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18
Commonwealth of Massachusetts
r� Title 5 Official Inspection Form
i i Subsurface'Sewage Disposal System Form -Not for Voluntary Assessments
84 Liam Ln
Property Address
Brenda Willis
Owner Owner's Name
information is Centerville MA 02632 3-17-20
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. 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
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: N/A
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc•rev.712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
r Commonwealth of Massachusetts
,'. Title 5 Official Inspection Form
>i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
84 Liam Ln -
Property Address
Brenda Willis
Owner Owner's Name
information is required for every Centerville MA 02632 3-17-20
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system(yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract (to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
1983
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 18"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.):
Good condition.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
1bt Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
84 Liam Ln
Property Address
Brenda Willis
Owner Owner's Name
information is required for every Centerville MA 02632 3-17-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank (locate on site plan):
Depth below grade: . 12"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) El Yes ❑ No
Dimensions: 1000 gal
Sludge depth:
6"
Distance from top of sludge to bottom of outlet tee or baffle
26"
Scum thickness 0
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle
16"
How were dimensions determined? Tape
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 is in good condition with baffles installed and no sign of leakage.
t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection form
w_
cl�l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
:: >r 84 Liam Ln
Property Address
Brenda Willis
Owner Owner's Name
information is required for every Centerville MA 02632 3-17-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene, ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. 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
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
i;l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
84 Liam Ln
Property Address
Brenda Willis
Owner Owner's Name
information is required for every Centerville MA 02632 117-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank (cont.)
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
9. 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.):
Good condition with water at working level and no sign of back-up from pit.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
Commonwealth of Massachusetts
.� Title 5 Official Inspection Form
i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
84 Liam Ln F
Property Address
Brenda Willis
Owner Owner's Name
information is required for every Centerville MA 02632 3-17-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. 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.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
® leaching pits number: 1-1000 gal
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number,dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18
1
Commonwealth of Massachusetts
r� Title 5 Official Inspection Form
,�i
;� wa
Subsurface Sewage Disposal System Form -Not for Voluntary,Assessments
84 Liam Ln
-.=r•
Property Address
Brenda Willis
Owner Owner's Name
information is Centerville MA 02632 3-17-20
required for every '
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leach pit in good condition and empty at inspection with stain line at 24" off bottom of pit.
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
C��,," Commonwealth of Massachusetts
1� Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
84 Liam Ln
Property Address
Brenda Willis
Owner Owner's Name
information is required for every Centerville MA 02632 3-17-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. 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.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•.Page 15 of 18
I
Commonwealth of Massachusetts
,w Title 5 Official Inspection Form
N Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
84 Liam Ln
Property Address
Brenda Willis
Owner Owner's Name
information is required for every Centerville MA 02632 3-17-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. 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
i
8
, ' .
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
I
r 1, Commonwealth of Massachusetts
Title 5 Official Inspection Form
1�i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
84 Liam Ln
Property Address
Brenda Willis
Owner Owner's Name
information is required for every Centerville MA 02632 3-17-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)*
15. Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to!high ground water: 20'+
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:
USGS and town maps show groundwater at 20'.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18
Commonwealth of Massachusetts
ra Title 5 Official Inspection Form
I,i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
84 Liam Ln
Property Address
Brenda Willis
Owner Owner's Name
information is required for every Centerville MA 02632 3-17-20
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
Commonwealth of Massachusetts
Executive of Environmental Affairs AUG 1y
DEP4ti
Department of
Environmental Protection 4 g
I 0 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 84 Liam Lane. Centerville, M a.
Address of Owner: Robert P. &Janice A. G enovesi
(if different) 1 Bath Crescent Lane. Bloomfield,CT 06002
Date of Inspection: 07/29/96
Name of Inspector: Michael DeDecko
Company Name, Address and Telephone number: Atlantic Environmental
P.o Box 2384 - M ashpee Ma 02649. Tel : (508) 4771420
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
�c Passes
---- Conditionally Passes
---- Needs further evaluation by the local Approving Authority
---- Fails
Inspector ' s S ignatur 4 Date: 07/30/96
The system Inspector shall submit a copy of this inspection report to the Approving
Authority within thirty (30) days of completing this inspection. I f 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 or the Department
of Environmental Protection.
The original should be sent to the system owner and copy sent to the buyer, if applicable
and the approving authority.
Y
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 84 Liam Lane. Centerville,M a.
Owners : R. Genovesi
Date of Inspection : 07/29/96
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 CM 15.303. Any failure criteria not evaluated are
indicated below
B) SYSTEM CONDITIONALLY PASSES:
---- One or more system components need to be replaced or repaired. The system,upon
completion of the replacement or repair,passes inspection.
Indicate yes, no, or not determinate (Y,N, or ND). Describe basis of determination in all
instances. If "not determinated", explain why not.
---- The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or
exfiltration, or tank failure is imminent. The system will pass inspection if the existing
septic tank is replaced with a conforming septic tank as approved by the Board of
Health.
-- 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).
----- broken pipe(s) 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
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 84 Liam Lane. Centerville, Ma.
Owner: R. Genovesi.
Date of Inspection : 07/29/96
C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
---- Conditions exist which require further evaluation by the Board of Health in order to de-
termine if the system is failing to protect the public health , safety and the environ-
ment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE
SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE
PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
---- Cesspool or privy is within 50 feet of a surface of water
---- Cesspool or privy is within 50 feet of a bordering vegetated wetland or a small
marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND-PUBLIC WATER
SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNC-
TIONING INAMANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY
AND THE ENVIRONMENT.
---- The system has a septic tank and soil absorption system and 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 is within a Zone I
of a public water supply well.
---- The system has a septic tank and soil absorption system and is within 50 feet
of a private water supply well.
---- The system has a septic tank and soil absorption system and is less than 100
feet but 50 feet or more from a private water supply well, unless a well water analy-
sis 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 notrogen is equal to or less than 5 ppm.
D) SYSTEM FAILS:
-- I have determined that the system violates one or more of the following failure criteria
as defined in 310 CM R 15.303. T he basis for this determination is identified below.
The Board of Health should be contacted to determine what will be necessary to cor-
rect the failure.
--- Backup of sewage into facility or system component due to an overloaded or
or clogged SAS or cesspool.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 84 Liam Lane. Centerville, Ma
Owner: R. Genovesi
Date of Inspection : O7/29/96
D) SYSTEM FAILS (continued)
-- 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 over-
loaded or clogged SAS or cesspool.
--- Liquid depth in cesspool is less than 6" below invert or available volume is
less than 1/2 day flow.
--- Required pumping more than 4 times in the last year NO T 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 cesspool or privy is within 100 feet of a surface water supply
ortributary 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 ana-
lysis. 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.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
a
Property Address: 84 Liam Lane. Centerville, Ma.
Owner: R. Genovesi
Date of Inspection: 07/29/96
E) LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above :
The design flow of system is 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 :
--- 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 I I of a public water supply well
The owner or operator of any such system shall bring the system and facility into full compli-
ance with the groundwater treatment program requirements of 314 CM 5.00 and 6.00.
Please,consult the local regional office of the Department for further information.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 84 Liam Lane. Centerville Ma.
Owner: R. Genovesi.
Date of Inspection: 07/29/96
Check if the following have been done :
-x Pumping information was requested of the owner , occupant and Board of
Health.
--x None of the system components have been pumped for at least two weeks
and the system has been receiving normal flow rates during the period. Large
volumes of water have not been introduced into the system recently or as part
of this inspection.
--x As built plans have been obtained and examined. Note if they are not available
with N/A.
--x The facility or dwelling was inspected for signs of sewage back-up.
--x The system does not receive non-sanitary or industrial waste flow.
-x The site was inspected for signs of breakout.
--x All system components, excluding the S oil Absorption System, have been
located on the site.
--x The septic tank manholes were uncovered,opened and the interior of the sep-
tic tank was inspected for conditions of baffles or tees, material of construc-
tion, dimensions, depth of liquid, depth of sludge, depth of scum.
---x The size and location of the Soil Absorption System on the site has been deter-
mined based on existing information or approximated by non-intrusive methods
---x The facility owners and occupants if different from owner were provided with
information on the proper maintenance of Subsurface Disposal System.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 84 Liam Lane. Centerville, M a.
Owner: R. Genovesi
Date of Inspection: 07/29/96
RESIDENTIAL:
Design flow : SN3 gallons
Number of bedrooms :o-_',
Number of current residents: o-z—
Garbage grinder(yes or no): 0
Laundry connected to system (yes or no):
Seasonal use (yes or no): ►jv
Water meter readings, if available:
Last date of occupancy : Vjwaq_.--�—
COMMERCIALANDUSTRIAL :
Type of establishment:
Design flow : gallons/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 INFORMATION
PUMPING RECORDS and sourEe of information:
System pumped as part of inspection (yes or no) :..... ........
if yes, volume pomped : .................... gallons
Reasonfor pumping :............................................................................................................
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORA
PART C
SYSTEM INFORMATION (continued)
Property Address: $4 Liam Lane. Centerville, Ma.
Owner: R. Genovesi.
Date of inspection: 07/29/96
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)
--- Other (explain)...........................................................................................
APPROXIMATE AGE of all components, date installed (if known) and source of information
Pry ?x. . !o..:.....!�°. ..........................................................................................
................................................................................................................................................
................................
Sewage odors detected when arriving at the site : (yes or no)....tom...
SEPTIC TANK : ......
(locate on site plan)
Depth below grade: ..�.....
Material of construction: A.. concrete ......... metal ........ FR P ........ other (explain)
................................................................................................................................................
Dimensions: xr�.. . S
Sludge depth :....?.`'.......
Distance from top of sludge to bottom of outlet tee or baffle:.........3`!...............
Scum thickness 6 ``
...... ..............
o�
Distance from top of scum to top of outlet tee or baffle: .............. p...................
Distance from bottom of scum to bottom of outlet tee or baffle :.....1.b................
Comments :
(recommendation for pumping ,condition of inlet and outlet tees or baffles, depth of liquid
level in relati n to outlet invert, structural integrity, evidence of leaks e,etc.)......................
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 64 Liam Lane. Centerville, M a.
Owner: R. Genovesi.
Date of inspection: 07/29/96
GREASE TRAP : .....0.0.....
(locate on site plan)
Depth below grade: ...............
Material of construction: ........concrete.........metal........FRP........other(explain)....
..........................................................................................................................................
Dimensions:...............................
Scum thickness:........................
Distance from top of scum to top of outlet tee or baffle:.......................................
Distance from bottom scum to bottom of outlet tee or baffle:...............................
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.)........................
.. ................................................................................................................................................
TIGHT OR HOLDING TANKS:...lNh...
(locate on site plan)
Depth below grade:...............
Material of construction:........concrete........metal.........FRP..........other(explain)..........
...................................................... ........................................................................................
Dimensions:............................
Capacity:....................gallons
Design flow:...............gallons/day
Alarm level:.............................
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
......................................................................................................................
................................................................................................................................................
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PAR T C
SYSTEM INFORMATION (continued)
Property Address: 84 Liam Lane. Centerville Ma.
Owner: R. Genovesi
Date of inspection: 07/29/96
DISTRIBUTION BOX:.. 5
(locate on site plan)
Depth of liquid level above outlet inverk:.f�J.......t,,,t �
Comment:
(note if level and distribution equal eviden e f s lids carryover,evidence of eakage into
or out of bo etc.). -. q?� -�►� 9 .
....: .... ...... ... ... .. .... ...
t.. °�.. V.l �.... . . .
................................................................................................................................................
PUMP CHAMBER:....1
(locate on the site)
Pumps in working order: (yes or no)...............
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)....................
.........................................................................................................................................
...............................................................................................................................................
SOIL ABSORPTION SYSTEM (SAS):....
(locate on site plan, if possible; excavatio�t required, but may be approximated by non-
intrusive methods)
if not determined to be present, explain:
............................................................................................................
Type......................................................... ....................................................................
leaching pits, number: ..�. � k
leaching chambers, number:........
leaching galleries, number:...........
leaching trenches, number , length:.....................
leaching fields, number, dimensions:...................
overflow cesspool,number:..........
Comments:
(note an kian of soi ,signs of hydraulic failure, level of ponding, condi n of g ation,
• SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property address: 84 Liam Lane. Centerville Ma.
Owner: R. Genovesi
Date of inspection: 07/29/96
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: .....................
Indicator 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 the site)
Material of construction: ...................................
Dimensions: ......................
Depth of solids: ................
Comments:
(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation,
etc.) .
................................................................................................................................................
� V
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
I
' Property Address : 84 Liam Lane. Centerville, M a.
Owner: R. Genovesi.
Date of inspection: 07/29/96
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks locate at
wells within 100'
03
DEPTH TO GROUNDWATER:
Depth to groundwater: :+.�.O.feet
Method of deter0nation or approximative:
.Utz\.. r-a- ..... 1.110
..............................................................................................
I
GJ
LOCATION SEWAGE EpqIT NO.
VILLAGE
INS TA ER' NAME A00IttSS
_ .
11UILDEIt OR OWNER
0A T E PERMIT ISSUED
DATE COMPLIANCE 15SUE0
't sce-
�� �(�
�`�
��I
�;s
�i/�%
.. ,�qt
No......................... Fn$..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
�..w . ....-.....oF............. - .1
Applirtation for Uhspooaal Works Tontfur#ion ramit
Application is hereby made for a Permit to Construct (1< or Repair ( ) an Individual Sewage
Disposal
System at: .............r.............. .................. ...... ....... . ...................................
-
- 1 ocation-Address. or Lot No.
. . ................. 6� `air.. i3.t ....-•-- ----------------jab- -�1-0-----•----• - • ••...._._........
Owner Address
a --""-""""""-"-----"""--".......... ----""Pfusx.-Oy/........ ..........................._..._...... . ....____..._______-------------...-
Installer Address
d Type of Building Size Lot....��t_ d_ ...Sq. feet
U Dwelling .No. of Bedrooms.........._ _Ex Expansion Attic (,4b Garba e Grinder A,
Other—Type of Building ............................ No, of persons............................ Showers ( ) — Cafeteria ( )
a' Other fixtures .................................
Design Flow.....................j .........gallons per person per day. Total daily flow._._...............3..�._o...........gallons.
W "
WSeptic Tank—Liquid capacit��_Q.gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No.............:....... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No-_-------_------- Diameter---____-"___-______- Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box Cl�) Dosing tank ( )
Percolation Test Result Performed by---------------------_2L _!'T�c_...._ ... Date.......*ti.2.7.E_.�'Z__..
Test Pit No. 1.....1 CI.minutes per inch Depth of Test Pit.._--_-_. Depth to ground water...... v
Gz, Test Pit No. 2....._., ....minutes per inch Depth of Test Pit.......7� epth to ground water-__-1;
......k............41 . ............•---•-— ti _
xDescription of Soil.........................................�F� 1 1-••-----•-_-----U�4- - �.d .. ....; -
c.� ------------------------------------------"--------------------------- f- •-_........"%Yl_� ...t.�- --"" r
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 TITLL 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.
11Z4
n g DApplication Approved B ..................•--•......•-- _. . ..� ---...._...
Date
Application Disapprovedowing reasons:------""------------"-"------•--------------•----------------"•"----------"----•------•---.
...................•--........••-•-_......_.•••---...•-•-•.....-•----•--------••.____..........._..._•-•------•-•-------•-•---------------•-•-----------------•-•----•-•-•--•..........................
Date
PermitNo......................................................... Issued.......................................................
— Date
.................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
f ` •—...............OF..............'=..,'A-V5 4 1. 1�
.. ..................................................................
Appliratiun for Uhipaii al Workii Towarnrtion Permit
Application is hereby made for a Permit to Construct (/(\') or Repair ( ) an Individual Sewage Disposal
System at:
G.._ :..> t Z ♦' r Y;:!'�:!✓ .�`f l A
................_........................... ...............................
Isocation-Address .... or Lot No. ..
....................... ... ..
Owner f j Address
W .................................... - 4yo < C ✓z C nlr:. r?r ..a.---••-......•------------------------
1.4 Installer •� � rAddress_
dType of Building Size Lot.... . ?.:.` _I!. ...Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic (,4b Garbage Grinder
'4 Other—T e of Building ............................ No. of persons............................ Showers — Cafeteria
a' Other fixtures ............................... . .
W Design Flow____________________`_._:"____________gallons per person per day. Total daily flow................... ._ __!1...........gallons.
WSeptic Tank—Liquid capacity._:....!?_gallons Length................ Width................ Diameter--.---___-____- Depth................
x Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Other Distribution box (.a) Dosing tank ( )
Percolation Test Results Performed by......................... ...f"!�'.!�..�___.._ ✓�___. Date...._. ..........
Test Pit No. 1.......'S .minutes per inch Depth of Test Pit_......__a>:,_.__ Depth to ground water_.....�,_y;_r_. .
fs, Test Pit No. 2___....%nlinutesper inch Depth of Test Pit_______ _ _____ Depth to ground water-_. '- - c
--------------------------------- ...-•;............. .................................• ;........
Description of Soil.................. n t' -4 S �,1........ . .................
:.. ..... ...•... .....-•-.....-•-- ---
(xj = -= �.. = -
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 TIT1L 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.
ign ............S� ..._ ...
4
lols
Application Approved B r----•-••----•-•-•-----•--•----•-•--.....----•---•----•-••-•--...-•---• r �- -----
Date
Application Disapprovedng reasons_________________________•-------------......--•--._..----•---•-•--•----•-------•-----------•-._..._....._--•---
�.-,
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
_ BOARD OF HEALTH/
...............wr....'`.................OF.......... l A !%:"..fi33:' rc.................................
(Inrtifiratr of TompliFanrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ') or Repaired ( )
r Installer
at........................................................`�-- T/ /•• '�' ...--.. � ==f' ` ''�='
.................
has been installed in accordance with the provisions of TITIZ 5 of The State Sanitary Co . a described in the
application for Disposal Works Construction Permit No.13.::_f.P----------------_- dated.J� _r,3..........................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE S A GUARANTEE THAT THE
SYSTEM UNCTION SATISFACTORY.
DATE...., ... ............................................................ Inspector--------- --- •---=-•----••••--•-----•-•--------.._....._.......---------......._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
013
N(V.._v,.'.................. FEE..'ele.............
�t��osaal urk��on�#riun rrTrai�
Permission is hereby granted .f _(.5._!�..... Z.......................................
to Construct (__�or Repair ,( ) an Individual Sewage Disposal System
Street
as shown on the application for Disposal Works Construction Permit No................. -' d-� _"-:<�_.,_ ..__.________.___....
f.
.....................................
--•------------------------------- :_- - ''............................._ -
B d of Health
DATE-3• ---�......................••--••.........----•----........
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS
ru614ATES.c.
110
i
�ij4
� til. r
` Q. A�1E � b• iR. 6 �
H
o ,ry
S y , E ERG y
No. 366 Q , ? l S w I L-.Il I
?�@�BTERfi OAF G'ISTS 4k' QQ F.`— B.
4w SUR� O ONAL
LEGEND CERTIFIED PLOT PLAN
EXISTING SPOT ELEVATION OxO
EXISTING CONTOUR ---- 0 --- lr r 14 - Li A &A LAi-iE-
FINISHED SPOT ELEVATION C L1-T1✓E\-lI L.LE-
FINI SHED CONTOUR 0 —
IN
APPROVED , BOARD OF HEALTH Tf3nn@-re�P
EU. 3�o a
DATE AGENT SCALE, I "= 5cv1 DATE., of I S•83
DREDGE ENGINEER/NO CQ IN CLIENT "
1 CERTIFY THAT THE PROPOSED
EGISTEREa 8TE-REQ J06 N0.�� is BUILDING SHOWN ON THIS PLAN.
CIVIL LAND CONFORMS TO THE ZONING LAWS
DR. . �--- -- TAB ASS.
EN® NEER �SMRY OF BARNS ,
Pw: .
712 MAIN STREET.. CH, 8Y$.......,-----,... .
N YA NN I S, MASS. 1SHEET..1=
OF DATE R LAND SURVEYOR .
/VOTE /F E/'TNER THE.Sz P7 C TAN K OR
20 FT. MIN. 1E.4cwlovG P/T ARE MORE TNA:'/. /Z"BELOkv
/p pT.:MIN 1RADEF A 24 O/.METER G'oNCRET� COiiE/r
SjlALL S.F 9R0UCsHT To GR.4 taE:6-;;v ZX RA
E
PYC P!P G�
CONG4ETC 9 tIEAYy Cr'1 ST /RaN 1/ER Sf/.4 L L •�E USED
M/N. P/TCI+I /F%N O4el vzWA r
` 2 • MiN. CONER�TE
A G ,•ICE CO 1- CG EAN .SANG
/ �• d.1CX�/G4.
.j upu/o LEVEL
2'LAYER
*0 CAST
IRON PIPS• I OCR® GdL...
M/N.PM D/ST. • '� / t • • • • • d �4 WA SHFO 57CIVe
•- • . � • s
%v RAW P7: SEPTIC TAIYfC , . • . • • •,
BOX a t • t I 8 •. • • •
s. . • . • OtPTH • • I • . • WASXEO. STOrYE .
_ - O t• -• • • ••1 I s a •
.. . PRECAST,SEEPAGE
• e�. • �' •- It • • • • d a•r lNi/P�t'T ELEYAT/aNs. I�•5 X 2.5 =' 4�1 -�/� � ` • ,. r ,- . •• . : . . . � • o ; v/7 oR E4u/V.
INVERT .4T 4t/1LD/NG ;. 40.� FT.
LO C SFE TAB[1L.4T10-V
G J
INLET .SEPTK- Ti4NK.; . 37• o FT. P(TCPAG�T�f . . 54-�
FT. �J'
?i.
DttTLET SEPTIC TANK _FT.
1A LET O/STRIBNT/ON BOX Vic-=Fr. SECT/ON O� GROuNO YE�4 TADLE.
4
O07L' ZrD/STR/BVTYONBQX 3L__FT.
SEWAGE O/SPO�SA L SKS7...
T LFAGy/HG PIT 3S.3 FT. T 8ULAT/DIV
/wtE A
HUNG =/7'
L F�4C •
FT
SCALE Y4. D/MENS/ON �A 3 .
DESla)V CAITERIA -fT-
NUMBER OF BEDROOMS 3 - DIMENS/CN C�._F
C,.�RaAGED/SPOSAL UNIT L1C1 �� SOIL LOG SG/L TEST
TOTA4 E.3T/1.jr4'T'EO FLO rV 55cO 49.4Z..1DAY SO I L TEST A/ SOIL TL-ST �
NUMBER 4F A[IVING PITS_ I �^ELEK 31.3 �"ELFY• oA OF SOIL TEST N�L��ILI,. I 82
S/DELEACH/NG PERP/T 18g Sa. PT. LCIANA RES/JLT.S iV/TNESSED dY
90TTOM L •!CN/NG PER P/T ��' S4. FT PERCOLATION MATE#I _� M/N�//NCH
TOTAL LEACH/NG ARE^ 2�° SQ, FT. /7 FlEIlCOL.�►7"/ON RATE, 2 FAQ M/N.//NGH
RFs�RKELEACYIh'GAREASQ. FT.
M�ivM ILEF L
�a OF `�5� �� 18 t� L��- ilk. - L i A M LAQ�
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