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HomeMy WebLinkAbout0191 OLD POST ROAD (CENT.) - Health (3) 191 OLD POST ROAD, CENTERVILLE A= 209 052 �Illl �,�aFo�m NOp2�-15�235�OR �qma HASTINGS,MN COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF E?,�iIRO'��4E�TAL AFF.AI DEPARTMENT OF EN-VIRONNIE\T,AL PROT ON 4 a ONE WINTER STREET. BOSTON. NIA 0210S 61 9:-c_(10 Q JUL-. ..1. 1998.... 1>b�6Fd�Ej R7LL1��•.F.WELD 9iEAUHlIEPL TR �. Gov=c S :rc ARGEO PALL CELLL'CCI __. .. STRD LLGov or SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM g Commissior 04ftv —Ao \ PART A .� . thT osu)02, CERTIFICATION okk�St �c Property Address; t�� Address of Owner: ' Date of Inspection: t�1 .0 -� L_)�• :(If different) Name of Inspector: 1 J �� 32 ...•.`. . . . 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 3 (310 CMR 13.000) Company Name:&ita ar-,L�'c Eir v'1'rC-7 K •" e H 4-�-_/ Mailing Address: 2 Q /3o,t e-37? H/gS , - - J 0 2C4-C/ Telephone Number: SSG 7� !6!=qw';J— r. Zo \ CERTIFICATION STATEMENT I eenif) that 1 have personally inspected the sewage disposal syste^� at this address and that the information reported below is true, accurate and complete as o:the time of inspec.o�. The inspection was performed base: on my training and experience in the proper•function and maintenance of on-sae sewage disposa; systems. The wstern.: Passes _ Concit-onaiiv Passes Neecs Furthe- E%•a!uat 5y the local Approving Authorir, Fa.:s :�A Q Inspector's Signatur Date: T;ie S,.•s:e^ Ins•:e:o- sha!! submit a copy of this inspection report to the Approving Authority, within thin (30) days of completing this inspecoon. If jhe system is a shared s\•stem o• has a design flow of 10,000 gz or greater, the Inspector and the system owner shall submit the repo, to the appropriate regional office of the Depantment of Environmenta' Protection.. The orig:na! should be sent to the system ow•nt and copies t-nt to the buyer. if applicable. and the approving authority. INSPECTION SUMMARY: Check A, B, C, (w D: Al SYSTEM PASSES: - I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.30, Any failure criteria not evaluated.are i('�icated below. COMMENTS: S r �i53�8 �x�-Tkk- ,Lt Tr.—L N P o • Z. BI SYSTEM CONDITIONALLY PASSES: One or more system components as described in the 'Conditional Pass' section need to be replaced or repaired. The system, up, completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes. no. or not determined (Y, N. or NDi. Describe basis of determination in all instances. If`not determined', explain why not. _ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificat e of Compliance (attached) indicating that the tank was installed within twenty (201 years prior to the date of the. inspection; the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tar 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. trev.eed 04/25l17) Pace i of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) ,,P.roperty-Addr4ss: , — -4-a-.�•k:Cl CO fj (Owner ?.' . Date oln;.pection: Bl SYSTEM CONDITIONALLY PASSES (continjd• - V Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed _ pipets) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the 'Board of Health). Describe observations: Y �.r brokers pipe($) 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 pipets)..The system will pass inspection if twith approval of the Board of Health): broken pipets) are replaced obstruction is removed - - :.•. CJ FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: . - Conditions exist which require furthe•evaluation by the Board of Health in order to determine if the i}•stem is failing to protect the public health. saie-v and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM 15 NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE-PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or priv% is within 50 fee: of a surface water Cesspool or pn%N is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: ` The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 fee: to a surface water supply ar tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supoiy well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less thar. 100 feet but 50 feet or more from a private water supply well, uniess a well water analysis for coliform bacteria and volatile organic compounds indicates tha the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than S ppm. Method used to determine distance (approximation not valid). 3) _.OTHER �. .. � _ ~ .. � - .. ,- .�. �. .._._ -.4 '1• Iw•.lam: •: •• � • (revised 04:25/3:) page 2 of 20 IL �e SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Addross: Owner: Date of Inspection: 01 SYSTEM FAILS: You must indicate either 'Yes" or `No' as to each of the following: I have determined that the system violates one or more of the following failure criteria a-, defined in 310 CMR 13.303 The basis for this determination is identified Wow. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SA5 or cesspool. _ Discharge or pondrng of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Stoat !reutd levei in the drstnbitron bo), above outlet invert due to an overloaded or clogged Sq5 or cesspoo: Lraurd depth in cesspool is less than 6- below invert or available volume is less than 1/2 day ilov. Reeuired pumping more thar. 4 times in the last year NOT due to clogged or obstructea pipe s . Number or times pumped _. An%- portion of the Soa Ansorption System, cesspool or prry)• is below the high groundwate• eievation Ary por::on o:a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supple Any por:ron of a cesspoo: or priv-y is %rthrr. a Zone I of a public well. An% pc^ro- e:a cesspool or privy is within 50 feet of a private water supple well Any por.or. o:a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceo;able -ate, qualm analysis. li the well has been analyzed to be acceotabie. arach copy of well water analysis for cohiorm.. bacteria volatile organic compounds, ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: 'rou must indicate either "Yes- or 'No- as to each of the following. The ioliow.ng criteria app;% to large systems in addition to the criteria above: The system serves a facit,t\ with a design flow of 10,000 gpd or greater (Large System; and the system is a significant threat to public hea!th and saiet� and the environment because one or more of the following conditions exist. Yes No . the system is within 400 feet of a surface drinking water supply - the system is within 200 feat of a tributary to a surface drinking water supply - the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area - IWPA) or a mapped Zone II'of a public water supply well) __... ..-_.. . .__... The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater.treatment_program - - requtrements..of 314 Ch1R.5.00 and 6.00. Please consult the local regional office of the Department for_turthe.r.informacio4' .-_- (r.v%sod 04/15/97) Ri f SUESURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1 j 60 �> Owner:Lq V()1 E Date of Inspection:6(C.�, Check if the following have been done: You must indicate either "Yes' or 'No' as to each of the following: Y N. ' Pumping information was provided by the owner, occupant, or Board of Health. _ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as pan of this inspection.. As bull: plans have been cotained and examined. Note if they are not available with NIA. The fac:lm or dwelling was inspected for signs a-sewage back-up. The system does not receive non-sanitary or industrial waste flow. The site %%as inspected for signs of breakout. All symerr. components. excluding the Sod Absorption System, have been located on the site. _ The septic tank manho;es mere uncovers:_. opened. and the interior of the septic tank was inspected for cond,tion of baffies or tees. materta: a:construction. dimensions, deptn of liquid, depth of sludge. death of scum. The size and locat-on of the Soil Absorption Svstem on the site has been determined based on k _ The facdw, o%%ne• .ano occupants. r draeren: from owner were provided with information on the prope• maintenance of Sub-Surface Disposal Svstem. 1� Existing iniormation. E> Plan at 6.0 H. _ Determined to the field u;am of the failure*criteria related to Part C is at issue, approximation of distance is unacceptabie (15.302:3):bl? SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR.M PART C r/ SYSTEM INFORMATION A^ddress: �� � �i� �O;J Owner:lA v v j<-, Date of Ihspection: FLOW CONDITIONS RESIDENTIAL: Design iio%,% _'U e p.d2bedroom io. S.A.S Number of bedrooms Number o'current residents--!LW Garbage g•::der (yes or no!: Laundry tor•^ected to system (y1s or no! Seasonal use (yes or no!:—h,-) Water meter readings. if available (last two i2 year usage tgpd(: Sump Pump Ives or nov Lac dare of occupanc-,• -4 V14 COMMERC i 4L'INDQSTRIAL: Type of establishment Design fio%% eahonsida% Grease trap present ryes or no_ Industrial 1laste Holding Tani: present. sves or no_ ':on-sanitan. Haste discnarger to the T!oe 3 s•stem Ives or no_ %%ater meter readings if availabie Las:Pa:e o: a OTHER. .Oe:cube Last sate of occuoanc. GENERAL INFORMATION PUMPING RECORDS and source of informat on "Ma. 0;,1/14 r System pumped as par, of ins c;ion: tves or no. AJA If yes, volume pumped. ¢allons Reason for pumping TYPE OF SYSTEM Septic tankldistnbuuon boxlsoil absorption system Single cesspool Ovenlow cesspool Prny Shared system (yes or no) (if yes, attach previous inspection records, if any) VA Technologv etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: t G Sewage odors detected when arriving at the site. (yes or no) tr.vlud 0�/2S/7�1 Y.q. 5 of 10 ,a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM IN-FORMATION (continued) Property Address: 6 601 P S Owner: �-qL4.6 Date of Inepectton: BUILDING SEWER: (Locate on site plan) ,gyp Depth below grade. Material of construction. _cast iron _40,PVC _other (explain! Distance from private water supply well or suction li-t Diameter Comments: (condition of joints, venting. evidence of leakage, etc.) SEPTIC TANKS (locate on site pl -� 4 Depth below grade Material of construction- concre:e _meta _Fiberglass _Polyethylene _othertexplain If tank is metal. Its: age _ Is age coniirmec o% Ce-..fica:e o: Compnance _(yes,-No Dimensions � Sy Sludge depth Dtsiance from top o: siuoee to bono-t of ou:.e: tee o• ba-":e Scum thickness-_ Distance from top of scum to top of outle: tee or ba=.ta 16N Distance from bottom of scurn to bo-. o .. o1 ouue: t e c- bar-e Now dimensions were determined Cilu Comments trecommendation for pumping. rondition o� inlet and outlet tees or baffles. depth of liquid lev l to reiatto to outlet ' Vert. structu I integrity, evidence of leakage, e:c.t V� n GREASE TRAP:_t (locate on site plan! Depth below grade: Material of construction: _concrete _metal Fiberglass _Polyethylene _other(expiain) 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 baffie: ..--. .. Date of last pumping: Comments: --"'(recommendation for pumping.-condition of islet and outlet tees or baffles, depth of liquid level in relation-te-outlet-invert,-structur--al— mtegrtty, evidence of leakage. etc.: SLISSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR-M PART C i 1 SYSTEM INFORMATION (continued) Property Address: `�� Q'0 �S! OHner: OnsUd 1Date of ection:� k TIGHT OR HOLDING TANK:•?ank must be pumped prior to, or at time, of inspection, (locate on site plan, Y Depth below grade. Material of construction _concrete _metal Fiberglass _Polyethylene ather(explain► Dimensions. Capacity-_ galions Design floe galtons'da. Alarm level Alarm in %:orktng orde• _ Yes. _ No Date of previous pumping Comments (condition of inlet tee. condition o= a!a•m and float switches. etc.) DISTRIBUTION BOX: S (locate on site p:a- Oe=:h o'houid le%e•. aoo-e oune: sn%e- Juno Comments 1� mote :: �•e! and des:r:b�t,or. is eaua' e� 'e�ce of solids carrti•over, e�idence ovtleakage i to or o t f boa etc.) i PUMP CHAMBER:—Lib (locate on site plan. Pumps in working order: (Yes or No- Alarms in working order (Yes or No- Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) SUBSURFACE 5EW'AGE DISPOSAL SYSTEM INSPECTION FORM PART C 9 SYSTEM INFORMATION (continued) Property Addr-ss: 1 i r ��G1{ PQj] Owner:!�( vi I.Z, Date of Inspection. SOIL ABSORPTION SYSTEM (SA5):U43 (locate on sue.plan. if possible: exca.a:lon not required. but may be approximated by non-intrusive methodso If not determined to be present, explain: Type: leaching pits. number._Aux� leaching chambers..number:_ leaching galleries, number: leaching trenches. number,tength: leaching fields, number, d,rne-uion.s overflow cesspool, number Alternative system Name of Tecnnotogv Comments mote condition of soli, s!grs of hydraulic failure• leve` o ponding, condiu c of veg tation, tc.) t 1 � A l� !ry CESSPOOLS: (locate on site plar. Numbe• and.conngura:,on Depth-top of liquid to inlet Inver, Depth of solids lave- Depth of scum layer Dimensions of cesspool Materials of construatoe Indication of groundwate- inflow tcesspool must oe pumpeC as par, of inspection', Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: ........ (locate on site plan) Materials of construction: - ' Dimensions: Depth of solids: _ _, •.__ Comments (note condition of soil, signs of hydraulic failure, level of ponding• condition of vegetation, etc.): (zrvisoe 04/25/9^.) Page 0 0! 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Propert% Address: old PGS 1 Owner: bcau 1,e, Date of In3pection-6 (/ !� ( SKETCH OF SEWAGE DISPOSAL SYSTEM. include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) �01 1� I�3 � 32 83 - � SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIO-N FORM PART C SYSTEM INFORMATION (continued) Property Address- l 6 (<5.1 Owner: �-Qudl'e- Date of Inspecuon: Depth to Groundwate Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained irom Design Plans on record Observation of Sue.(Abutung property. observation hole, basement sump etc.) Determine it from local conditions Cnec'K with Ioca! Board o- neaar- Chen. FE.MA Maps Check pumping records Check local excavato•s rns;aile•s 1--se L SCS Da:a a Desciibe in voxo\%-. v.oros r.o•.% %o�; es:abh5hed the High GroundNate! Elevation. (Must be completed: �, C,�.�'sun-�r� 31 frw�i�d .0�;15!9 page 10 of 10 Jf THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH '?'n..................OF....................................... . A ipfirtttinn for Uispnstt1 Ulorkii Tonstrudinn trrmit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal system t .. - n� �ocation.Add:ess... ;. -- or Lot No. •}- - w r ( ("//!`''/1Y Address...................................-...... W .................. --- ---------•- ........._ � .r.l ...... ................ M Installer Address fi Q7i Type of Building Size Lot32:.>.6.Z .-Sq. feet U Dwelling—No. of Bedrooms....... .....Expansion Attic ( ) Garbage Grinder ( ) '4 Other—Type T e of Building No. of persons............................ Showers W YP 6 ........................•--• P ( ) — Cafeteria ( ) a Other fixtures a .......y..................................... 55 5 w �s ............er Design Flow............................................gallons per person q d� Total �1iow............... �_...._... p o WSeptic Tank—Liquid capacityl000gallons Length__-._.... ... Width:.41 .. Diameter................ Depth.... _..e x Disposal Trench—No..................... Widths.... ...... Total Length.........F.... .. Total leaching area...................sq. ft. 3 Seepage Pit No..©�^..�-..... Diameter..��..e °Depth below inlet.. .�: Total leaching area.. ` `�5sq. ft. Z Other Distribution box Dosm Percolation Test Results,Z Performed by..7.-..A v.'' 5.. ......� .:........:.... Date...` .a Test Pit No. 1................minutes per inch Depth of Test Pit...\.��t___....._. Depth to ground water..hS?!%",- .......... Gz. Test Pit No. 2................minutes per inch Depth of Test 'Pit.................... Depth to ground water........................ Lei1.............. ... ........ -►r•-.••••••- 1 l _ •ir............. . ........................... O Descnption of Soil.....0 -2 ..:...... -• �v Sol 2� ��o YY%e- C.00Qt Se Sa.v. .............••--•------........�............... �e e ..c��..�--• .ah W .= :::. ...... �_.........� ..--•--•------------------------------------------------------------------------------•----------.-•-••........•-------- :/�f--•- `// � .....-••_ ... - --....•--- ........Nature of Repairs or Alterations—Answer when applicable............. <...`....I......f.--......� :...... �2.Sa�k/JIB' .............................•----..........---•------........_.... ................ --...----:........ ...___..........._.........___..... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of.:ITI.: 5 of the State Sanita*' ed The undersigned further agrees not to place the system in operation until a Certificate mpliance has y t boa eailth. .._ ............................................................. .... .[. .. . lf�a Application Approved By..._.. .n .. ................. .... 2te.. ..'�1 ... Vat Application Disapproved for the following reasons:....................................................................--...------................................ .......-•.........................................................................•---- ................... ...._.... .......... ......_............_..._.....................Date c.�1. ............. Permit No...... ...1�....`.� � --•------------•------- Issued... . ....--- ................................. s i f `No.. Z' �. �_ �v THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH at'r� �v\ ..............OF.....................................b, ......................................... Appliration for Disposal Works Tontnution 1hrutit Application is hereby made for a Permit to Construct (A or Repair ( ) an Individual Sewage Disposal System at: .../C�>\r-, -� C ._ L .. ..� 1 « '_ . 4S: � : _ Location-Address /� � t Wr Lot No.. W ��Y1"r"N l •/� .� Owner ....................................... Address ..................................._..... t .....1 � '�l yi Yt1»f�f r r1�'l/l�/�� Installer Address Type of Building ti Size Lot�J ,: ._t-- Sq. feet U Dwelling No. of Bedrooms._....a................ .Ex anion Attic a g— -••-------•� p ( ) Garbage Grinder ( ) p, Other—Type of Building ---.--_------------_---- No. of`persons...PJ...................... Showers ( ) — Cafeteria ( ) a Other fixtures '� iu��.... Design Flow...........................•-..---.----.-...gallons per person per'day. Total daily flow---..........---.-.------......_..........--gallons. WSeptic Tank—Liquid capacity AgO gallons Length. _r�-y:- Width:.A: �.- Diameter................ Depth".'42.e�- x Disposal Trench—No. ..... Width:.................. Total,Length ::.: Total leaching area..-...F.`.�:�:............sq. ft. 3 Seepage Pit No...'"--�`!���-.... Diameter..�r?._' Dep th below inlet.... Total leaching area - -sq. ft. Z Other Distribution box Dosing tank0.4 ( ) v w 5 5- Percolation Test Results Performed b Date..... y--........Y'�...,.�..................:-..--•--............. 1-1...... ......................... 04 Test Pit No. 1... -2_minutes per inch Depth-of Test Pit...-..�5?.2:+-.... Depth to ground water..-._,S'n:r ...... t.'.t5vv..% f� Test Pit No. 2................minutes per inch Depth of Test 'Pit.................... Depth to ground water....................... O Description of Soil....-�.` Q... .. �v_ Sc':i 1_ 2_4-_............ . . m e,ci..C on:� -•- ._... .=• ....::.................................... .. ... ........:........ V .................... ........•------- .._.__...... ----C.-. ----t':.._c------�C.----------- UW •--•-•-•..............................••-•----•-•---•------...---.....--------......---•••.........................._.. = = �......._.. Nature of Repairs or Alterations—Answer when applicable................................................... r> �?........����':.?>�l// ................................................................................................................................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage DisposaINSy�em in accordance with the provisions of .I.LZ 5 of the State Sanitary Code—The undersigned further agrees)"I to place the system in operation until a,�Cetificate ompliance has beenUsu ed by the-boo a d o�ealth. /rA y-.! ..... ....` f........ ... . � . Application Approved By... ,,,,_- �Z Date/ . � ................... - . Date Application Disapproved for the following-reasons:.............:........•---------------•-----------..................----------.....---••-•---•.................. --••-•------•................................•• •--•----ti---� --� Date -----•-----................... -----^-----•-•--•-........---------------•--------------•----------.. . .......---•- PermitNo...... .. .. -•--•---- ..................__ Issued........................................................ • Date THE COMMONWEALTH OF MASSACHUSETTS �l r/ BOARD---OF HEALTH to ri (Intif utt#r of Toutplittnrr THIS IS,�TO CER�IFY, That the Individual Sewage Disposal System constructed ((/)nor Repaired ( ) by.................................... .. ..:e:7)A)-";.- ._.... .... ....................... ............................................... Installer ' // at....--•...�.......... ......... GST." ' _.vl . ...... ( t-C J has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.. ...... dated....... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A�GUARANTEE THAT THE SYSTEM WILL FUNCTIO SATI FACTORY. DATE................................ ..Z�� �'...---........ .. Inspector.. .. ........._.._._......:.-----.................... ............. ;. THE COMMONWEALTH OF MASSACHUSETTS BOARD -OF HEALTH G? -h OF......................................................... .. "'.............. v No........................ Fzz...................... Disposal Works Tons rurtion 11amit Permission is,'hereby granted......An, ......... ........................................................................ to Construct (✓) or Repair (� ) an Individual Sewage Disposal System at No........... .............ZVZZ.?i/s 5/ ,.. ............... ..... ...._........................... Street � as shown on the application for Disposal Works Construction Permit No._____/.__...._ Dated.......f/?I! ..!.'......-•--------•-.......•-----•---•--•------•-----...-•..................••-----•---- / Board of Health DATE.............................••-..............?�I��.7 TOWN OF BARNSTABLE LOCATION `-1 ' C5�C5l �OS�`kU , SEWAGE # VILLAGE— t�'t-�d l�--- ASSESSOR'S MAP &c LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY I WO LEACHING FACILTIY: (type) Q , (size) k Cc NO.OF BEDROOMS fZk ' BUILDER OR OWNER LPAVG 1-,C� -PERIffI'DATE: 61 Q d 5 S, 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 on site or within 200 feet of leaching facility) Al Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leac rig facility) / , ��,� 14 Feet Furnished b $ Z 9 , fa- Grp-�-oMC7 LOCATION /SEWAGE - PERMIT NO. VILLAGE CENri/Z1//ll� �INSTA LLER'S NAME i ADDRESS A RAF/ t 77s- �3 (�B U I L D E R OR OWNER Gci Y Co Ilerr� DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED 2� 1 l-- r �A �'�� - �� i �-� �b � � rp �� � � � �. ��O SECTION — SEWAGE (O1-SEPTIC TANK !� 1 _ ,.D.,BOX - 0 I - LEACH - \` _ ZOt._II�1 F . TOP OF FON CC /�vy�V 5-3� kMSL)• 'T"OF1r8TOlb" �O - - .5(�^�[_•� i lot. ` . Vim. J .. .. / f WASHED STONE t# \ �\ O Q +� ( loll rn� - ^, `Lover Lo qq IN• OUT• iN• OUTSEP • IDp<y t \ `` / .JO e ( TATIC �7.55� ,'Zo ELEV. ELEV. ELEV. ELEV. �I , 4 i `7- ELEV. ELEV. 10-- - / -I OF 8s"-.1y=.. WASHED STONE / p� 5257 TEST HOLE LOG /o TEST BY 1 U t''/ �, f 1' (� ��� le J,O�`'I� / WITNESS e �4 ' / / ,J / ` O TEST DATE �ESiG1�1BEDROOM HOUSE 5 _ �/ �/ / T.H: 1 T.H. # 2 <- ,�(( ELEV.'1� ELEV. NO 5A II . ToP L-2 DISPOSER DISPOSER V 43 c>� PERC RATE MIN/IN. 3• /, FLOW RATE(10.3,19GAL./DAY) SEPTICTANK45,5& Z,_ { }' `/ ;`; / REO'D•SEPTIC TANK SIZE 1 0QC .46 / • �� 7 j LEACH FACILITY r SIDE WALL `� :Zr.��Z�7) • 1471 6 �I BOTTOn't L h� I.C>}: - G/D. J S TOTAL Z��o.�sc' _ ' j Q6. / •� �0 `Q c USE: 0 - LEACHING P�T WATER ENCOUNTERED LOTFh "(' 3 J V NOTES': (UNLESS OTHERWISE NOTED) 1.DATUM(MSL)!.TAKEN FRO `�11lts�l��QUADRANGLE MAP �$��114 OF 1 h� ` 2.MUNICIPAL WATER—( �:,-,_------.AVAILABLE � � . �? ` Q�• Z� ����_—— • 3.PIPE PITCH:W•'PER FOOT Q' ARNE H. 4.DESIGN LOADING FOR ALL PRE CAST UNITS:AASHO- -44 S.MIN.GROUND COVER OVER ALL SEWAGE FACILITIES:(1)FT. t OJALA 6.PIPE JOINTS SHALL BE MADE WATERTIGHT a+ CIVIL H 7.CONSTRUCTION DETAILS TO BE ACCORDANCE WITH COMM.OF MASS. No. 30792 STATE ENVIRONMENTAL CODE TITLE S .oa I _ f!S1 Of 1 SITE PLAN LOCUS: y 3 "Ol_D PO-aT RD . RNE A (cElv-rER S NAL ENGINEE! - REG PROFE ,if - _ M REF. _ - • • a2; c _ . do Wo c4pe en�ineejing •r n. ;Ja PREPARED FOR:.�I�/ `D1 p C> 571 CIVIL-ENGINEERS LAND SURVEYORS —i BOARD OF HEALTH R SURVEYOR ��IIrIN�.. . EC3.'l7AND CONTOUR$ (EXISTING)------------- �.°.+5f,4Y? F I �y_ AO� - PROPOSED)-0-0-0-0- APPROVED DATE 1-- MA I Y � SCALE Sac O 2 ( / i"2EUlDATE U J J ,