HomeMy WebLinkAbout0010 QUISSET ROAD - Health 10 QUISSET ROAD, CENTERVILLE
A=250125
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a ® �
5 35LO No. R
HASTINGS,MN
' 1
TOWN OF Aic�ti'ST� LE ✓
LOCATION ��� SEWAGE #
VILLAGE ASSESSOR'S MAP & LOT ✓d
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY 1.000
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS ?
BUILDER OR OWNER
PERMITDATE: 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) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facili ) Feet
Furnished by r.S, 7 I Z 31 9J-
r�`e
LOCATION C��CSS�f r SEWAGE PERMIT - NO.
VILLAGE
G�i,i►1`�.CLW Ll
INSTALLER'S NAME i ADDRESS
1C.
IUILOER OR OWNER
LAAl L
DATE PERMIT ISSUED
DAT E COMPLIANCE ISSUED 6
Ct�
21�01
No.. '3�5/ .......��............
THE COMMONWEALTH OF MASSACHUSETTS
—�^ BOAR® Off" HEALTH
i�(sOl ... . ..-..... OF......T .Rfi -.4 ..-.. ......................................
ApplirFatiou for Bispoii al Works Tonstrurtion Permit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
.. .......t .... �.G.�. - �- -. - .....a... d....... -'
C�9C1k:..✓..�..►.1......e..
Locatioh-Address LoN
` .. � ....__..................... � ....
O Address r ................................
n
Installer Address
Pq
d Type of Building Size Lot.... ®��
.e --Sq. feet
V Dwelling—No. of Bedrooms_________ ______________________________Expansion Attic ( ) Garbage Grinder ( )
'_l Other—T e of Building No. of persons............................. Showers — Cafeteria
a Other fixtures ..........................................
W Design Flow.................................•.......•__gallons per person per day. Total daily flow......:33.0..........................gallons.
WSeptic Tank—Liquid*capacity/I1 ..gallons Length.............•.. Width................ Diameter_------------- Depth.5-r15_ r-tWS+
x� Pg1 �0 _ •. Width.................... Total
Length
l g
a sq. ft.
Seepage Pit No - -.__ -- Diamet .. � De t below inlet.................. Totalleaachingarea.A.�._....sq. ft.
Z Other Distribution box ( ) Dosing tank
Percolation Test Results Performed by..1V,_ . a_ie_4''..z.Xs� ............. Date....` ` .,< _.3.........
a
Test Pit No. 1. .. -_-_minutes per inch Depth of Test Pit.................... Depth to ground water--4.D4- . .
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.___-_____---__----__-__
0 Description of Soil------®-•-- `A 1 " 5v..Sof ---------•-• — �5 -..j15'►�1................
x ` �'`
Bi ,mom •--------------------•------------------------------------------•-------•--•--------------............0.-------------•--
x .........................
U Nature of Repairs or Alterations—Answer when applicable......:it .........................................................................
..-------•--•--------------------------------------------------------------------------••-•-----•••-•-•-•••••••-----•------••••••-•••-•••-•••••----••-••••••••-•-•-•-•-••-••..................••.--•-_.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITIS 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has be i sued We boa o ea
ned.. . . . ........A. - ---------------•-••-••-•-•-••••••
Date
ApplicationApproved By........ ....... -•• ................................................................
Date
Application Disapproved f o the ollowing reasons:--•---•--------•----•--------•-------------------------------------------------------------•••••............••--
--•---------••-•--••--••••....--•--••-••••--•-•---••••-•-••••-------•-•••--••-••-••---......-•-•-•-•----.---••••••-••-••-•-••••-••••-••••-•-•--••-••----------••-•-••----••••••-----•--•-•-•••••-••-•---
Date
PermitNo......................................................... Issued.......................................................
Date
NoSj_'.!14 .... Fss.._.....��............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
t.Gld ?.V'1....... ...............OF...... �'.41+ �!).Z �?--� �t......................................
Appfiration for Disposal Works Tonstrn.rtion Famit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: /
... . ..���.! & � ca?i� r! 1�' ................................
Locatio -Addressr Lot N
---•-------•-•-------------• --1-�q�---.. .t ".�r? + .... .... ? gin w�,. ...
OwnQz •-••-•------•--••---•-•---•--•.Address
Installer Address
U Type of Building Size Lot__ feet
�.a Dwelling—No. of Bedrooms.......... ................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
a' Other fixtures .........................................____
d -----
r day. Total daily flow______ .?t?..........................gallons.
WSeptic Tank—Liquid capacity/Z)CO._gallons Length................ Width................ Diameter________________ Depth__ -rapr$C4
x Disposal Trench—No.____I______________ Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter...... Depth below inlet.................... Total leaching area_ 44......sq. ft.
Z Other Distribution box ( ) Dosin tank
Percolation Test Results Performed by.. ✓ ! _1 _I- .�a C .�4S______________ Date.... ,1 _ ...... {.
Test Pit No. 1_71�_.21,.___minutes per inch Depth of Test Pit____________________ Depth to ground water.. -t:-2._-!fit,
fZq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ -
--•- -••-•--•-•....----•--------••••--•••-•---•-••-•-•-•-•--j-----• •••-• :• ..............................------- - -----------
O Description of Soil......�- �,t - `� �`� ' i------- �._ g-"'......1....�. °"` _, ' ------------• o
W � Y ` t7 �cTt -----------------------•------- -- -- -----------------•-- -------- -------------.....----------------
x ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
U Nature of Repairs or Alterations—Answer when applicable_.... _________________________________________________________________________
----••--•-•-•--•--••-••--•--•--•-•---•-••-•-••---•-••------•---•••--•-•-----•-•••---........-•••••-•-•--•-•--•-•-----------------------••----•--•••---••-----•---••-•-•••-•.....---••-••-------...----•-
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT12 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has be 1 ued.> Ville boa o ea
Ele-1-47' ....................I............................ 10
Date
Application Approved BY--ltheollowi7ngreasons:
•- ................................................................... ........................................
Date
ApplicationDisapproved f o -•-----•----•••--••------•---------••••••-----•----•--•••--•-•-•---------------•••-•----•-••---•-••-•....-••---
•-------••-----------•-----•-------------------•--------------•-•---•-----------...-'------•-----------•-'-----------------------------•----•-------------------------------------.._Date-----...--•---
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
t..CAW.Wt.................OF......� i\ "A.. �.�. ...._..............................
(5rdifiratr of Tonipfianrr
THI . T CERTIFY, That the Individual Sewage Disposal System constructed (&, or Repaired ( )
bY- c= ._..._ ---•--- .................... ---- -------------
-------------------------•--------------------•-----------
I alle
at "�........ _-_ ---------------------------------
has been install in accordance with the pro sions of TIT F 5 of T1 A State Sanitary Cod s scribed in the
application for Disposal Works Constructio ermit No.____ 3'-_3�5._________.. dated_-- :_r__ _3____________________
THE ISSUJ N OF THIS CERTIFI ATE SHALT. NOT BE CONSTRII S A GUARANTEE THAT THE
SYSTEM WI/ZF�CTION SATISFACTORY.
DATE---- ---•- --- -----•------•-•-•--••----•---•---•----•••-----•--•---•-_. Inspector........ .... .....•••---•••----•----•• =
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...........................................OF.....................................................................................
0
No.. FEE._......................
inoa k Tonntrndion rrntit
Permissionis rYgeb ranted------- . ="----------------------•---------•--------------------------------------•-----------------•-•-•----------..._..-----•-•---
to Constru t or Rep ' ( ) an I ' 1 al S e Disposal System
atNo. .... ------•-........
Street
as shown on the application for isposal Works Construction Permit No_________________ e_--_,X';_ __.__._.___.___.__-.._....
----------------•--•-•--•--•-----•-•--- ------ ---------------------------------------•--------•--
rd of Health
DATE................ --•---•-•--------- Fp
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS A. — o
in
- -
I :
� I
BUILDING 5ECTION
SECOND FLOOR PLAN
a
Birchwood Construction(
Cr—I Contractors
Ghe(9,8)2W.,808 24 iLLUI
1 i- 1
I.
;__ � o•>...a cc..v -.., ,
- SULLWAN
,
i
51DE ELE'/ATION - - Cenlernue.tdA
FLOOR PLANS
AND
FIRST FLOOR PLAN /�� ELEVATIONS
Z-� A-1
SUBSDRFACZ BZWAGZ DISPOSAL SYSTZM INSUCTION YORK
Address of property C),U\ i S G!"T as
Owner's name ��,,,
Date of Inspection
PART A
CHZCKLIST
Check if the following have been done:
Pumping information was requested of the owner, occupant, and Board of
/ Health.
None of the system components have been pumped for at least two Weeks
and the system has been receiving normal flow rates during that
period. Large volumes of water have not been introduced into the
system recently or as part of this inspection.
= As built plans have been obtained and examined.. Note .if they are not
f available with N/A.
(/ The facility or dwelling was inspected for signs of sewage back-up.
The site was inspected for signs of breakout.
All system components, excluding -the SAS, have been located on the
• site.
The septic tank manholes were uncovered, opened, and the interior of
the septic tank was inspected for condition of baffles or tees,
material of construction, dimensions, depth of. liquid, depth of
sludge, depth of scum.
The size and location of the SAS on the site has been determined based
/on existing information or approximated by non-intrusive methods.
c/ F
The facility owner (and occupants, if different from owner) were
provided with information on the proper maintenance •of SSDS.'
SUBSURFACE SZWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION
FLOW CONDITIONS.
If residential
number of bedrooms
number of current residents
garbage grinder, yes or no*
-- laundry connected to system, yes or no
-- seasonal use, yes or no
If nonresidential, calculated flow: '
Water meter readings, if available:
tsz�-i Last date of occupancy
4
GENERAL INFORMATION
Pumping records and source of information:
System pumped as part of inspection, yes or no
if yes, volume pumped
Reason for pumping:
TypeiOf 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. Source of ;,
information:
Sewage odors detected when arriving' at the site, yes or no.
. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION PORK
PART B
SYSTEM INFORMATION Continued
SEPTIC TANK:
(locate on site plan)
U�
depth below grade: ido
material of construction: v Concrete metal FRP _other(explain)
dimensions:
slutiqdepth
distance from top of sludge to bottom of outlet tee or baffle
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
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles,
depth of liquid level in relation to outiet. invert, structural integrity,
evidence of leakage, recommendations for repairs, etc. )
DISTRIBUTION BOX:
(locate on site plan)
depth of liquid level above outlet invert
Comments:
.(note if level and distribution is equal, evidence of solids carryover,
evidence of leakage into or out of box, recommendation for repairs, etc.)
PUMP CHAMBER; .
(locate on sit plan)
pumps in working order, yes or no
Comments s'
�t ;(note condition of pump chamber, condition of pumps and appurtenances, ,•
recommendations for maintenance or repairs etc. ) t ,; '
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORK
PART B
SYSTEM INFORKATION continued
SOIL ABSORPTION SYSTEM (SAS) :
(locate on site plan, if possible; excavation not required, but may be
approximated by non-intrusive methods)
If not determined to b resen , explain:
Type•
leaching pits and number wk.,
leaching chambers and number
leaching galleries and number
leaching trenches, number, length
leaching fields, number, dimensions
overflow cesspool, number
Comments.:
r ',• (note condition of soil, signs of hydraulic failure, level of ponding,`
condition of vegetation, recommendations for maintenance or repairs,etc.)
,. CESSPOOLS (locate on site plan) :
v ,.number and configuration
depth-top of liquid to inlet invert
depth of solids layer y
depth of scum layer
dimensions of cesspool
materials of construction
indication of groundwater
inflow (cesspool must be pumped as
part of inspection)
Comments: {
n .r (note condition of soil, signs of hydraulic failure, level of ponding, ..,
, , condition of vegetation, recommendations for maintenance or repairs,etc.)
PRIVY: ,
(locate on site plan)
materials of construction
''dimensions
depth of solids
x{ �Comments: c
'Inote .condition of soil, signs of .hydraulic failure, level of ponding,
wcondition of vegetation,• recommendations for maintenance or repairs,etc. )
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION .FORM
PART B
SYSTEM INFORMATION continued
SKETCH OF SEWAGE I=SPOSAL SYSTEM:
.include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
�6it
S
DEPTH'TO GROUNDWATER
Pr'�t,p
depth to groundwater
4
method of determination or approximation: #
SUBSURFACE SEWAGE DISPOSAL SYSTEM ZNBPECTION FORM
PART C
FAILURE CRITERIA
Indicate yes, no, or not determined (Y. N, or ND) . Describe basis of
determination in all instances. If "not determined", explain why not)
Backup. of sewage into facility?
. .,. Discharge or ponding of effluent to the surface. of the ground or
• surface waters?
Static liquid level in the distribution box above outlet invert?
.�_. Liquid depth in cesspool <6" below invert or available volume< 1/2 day
flow?
4 Required pumping 4 times or more. in the last year?
number of times pumped
Septic tank is metal? cracked? structurally unsound? substantial
'infiltration? substantial enfiltration? tank failure imminent? :
Is `any portion of the SAS, cesspool or privy:
below the high groundwater elevation?
within 50 feet of a surface water?
within 100 feet of a surface water supply or tributary to a surface
water supply?
within a Zone I of a public well.
within 50 feet of a bordering vegetated wetland or salt marsh :
• (cesspools and privies only, II the SAS)? "
within 50 feet of a private water supply well?
less than 100 feet but greater than 50 . feet from a priv4te'water�
supply well with no acceptable water s ` ` "� .. pply, p quality analysis? . . If Lf the,;we A;= �•;
has been analyzed to be acceptable, attach copy of well`water analy fez`*�
..for coliform bacteria, volatile. organic compounds,. ammonia nitrogen „ h
and nitrate nitrogen. z'� #
r " s .
SUBSURFACE BENAGZ DISPOSAL 8Y8TEM INSPECTION FORM
PART D
CERTIFICATION
Name of Inspecto �
d
Company Name
Company Address
Certification Statement
I• certify that I have personally inspected the sewage disposal system at
this address and that the information reported is, true, accurate and
complete as of the time of inspection. The inspection was performed and
any recommendations regarding upgrade, maintenance and repair are
consistent with my training and experience in the proper function and
mahitenance of on-site sewage disposal systems.
Che one:
- I have not found any information which indicates that the system fails
. , . to adequately protect public health or the environment as defined in
# ' 310 CMR 15.303. Any failure criteria not evaluated are As stated in
,.° the FAILURE CRITERIA section of this form.
I :have determined that the system fails to protect public health and •
the environment as defined in 310 CMR 15.303. The basis for this
j determination is provided in the FAILURE CRITERIA section of this
form..
4 .,Inspector's Signature
I i .
x „Date'
Original -to system owner ye-5
-
Copies to:
Buyer (if applicable)
... Approving authority \\\
,,t
T __ ._PL. A IV TYPICAL PROFLI 6
SCALE - 1 " -
NOT TO SCALE-
. __�..._.
l8"S TD. L T. WG T C.I. MH CO VE-.R
4"C.I. PIPF_ ,� 4"BIT. FIBER PIPE-T/GHT JOINTS
��\ OUTLET L f VEL
FLOW L 1NE --- ij _i
T — ---- - � Q TO F/RST JOIN
OWEL L;NO L!o' (- 1 -------,� o O -=
C.I. TEE 14!�` `_-��•_�..- ■ 4 1�.�_—.! �i 2. �.._. ..—_,V�.,._
C.I TEE ► _- --`�-'--=-a s
STANDARD F'RECA.ST
.S'6,Q CONCRE 1 E/ ' 'GAl LON rG 2 O
SEPTIC TANK L_ ....-__
�. DISTR18UTION BOX
TO BE INS TA L L ED ON ;
a
LEVEL , STABLE BASE.
SEPTIC TANK
TO BF INSTALLED ON
LEVEL , STABLE BASE ;
tr d T' � _ 2" I./8, TO r'/2" WASHED PEASTO.Nx LEACHING P/T
ALL AROUND FREE OF IRONS, FINE"S BA SE- TO BE LEVEL
:,• AND DUS T /N PL AGE
BRICK B M(;W rAR COURT
/2" WA SHED CFiU,SHED
• a�' � AS RE`�71!!h'ED TO 3R!l�'r..= TO I-1 .
STONE ALL A OUNP FREE CF
COVER TO GRA�,E 24"C.1. MH COVER �� iROA15, FINES AND DUST IN PL4CF.
.._... _.___.... A/VD E"RAME
4- - - _ .. _ I _- LEACHING PIT`
?_d; c t `1/LET-- - FLOW LINE +SECT� �"""
T7 i }J I. CONCRETE TO BE 4 CO Psi 28 HAYS
2. REINFORCED WITH 6' x 6" N0. 6 GA. W.W.M:
d T 6 �. 2` AND 4` SECTIONS ARE AVAILABLE FOR GREATER/ t .
�' "► / c.6; i DEPTH REQUIREMENTS,
$ItTH 4-1 8 4, NUMBER OF PITS REQUIRED
a16 r P OUTER DIAMETER 8 >
s t-3111' INSIDE DIAMETER NOTE, EXCAVATE TO ELEVATION ,��-OR LOWER AS
f
i
- p21✓95 V i �.�_: _ REQUIRED TO REMOVE ALL LOAM AND CLAY BENEATH
PIT. REPLACE. EXCAVATED MATERIAL WITH CLEAN
GRAVEL TO DESIGNED GRADE
� �•.G•5.. Y 2 OaiG JrJ.:: •' � � I
4•) H
_ I -- - _. ..--- ---__.�
MIN. EFFECTIVE DIAMETER {
I 3 (NO T TO EXCEED 3 T/MES EFFEC TI VE DEP TH) d
-ti WATER TABLE
1-cZ rac TN g s/DE w,oL x ,SOIL A ND F'EfRC. DA TA ----- GENER,4 L NOTES
PERC. RATE .c 2 MIN. /IN . NO HEAVY EQUIPMENT TO RUN OVER SYSTEM
I � 44� �4 SEPTIC TANK, DISTRIBUTION BOX , LEACHING PITS TO BE STANDARD
N2Joa6 2i 1 EST BY: /-'e��` /yF/IJ LVit?1Ma N3�cz! /A*-) PRECAST REINFORCED CONCRETE UNITS.
/9p qr} WITNESSED BY: ,Po C1,=�p,e,D ,fJB'+/ ALL SYSTEM COMPONENTS SHALL BE INSTALLED IN ACCORDANCE
TO REVISED TITLE 5 OF THE STATE ENVIRONMENTAL CODE ,
TEST PIT GR. EL.: DATE'___ 41Z9fB-3
MINIMUM REQUIREMENTS FOR THE SUBSUFACE DISPOSAL OF
I
TEST PIT NO. 1912 TEST PIT NO SANITARY SEWAGE EFFECTIVE I JULY 1977
9 0 0" ANY CHANGES TO THIS PLAN MUST BE APPROVED BY THE
y TisP �S�.e.so�� Tom a.Su�J.�olL
E 2' 2• BOARD OF HEALTH.
CC.92 SE 3igN
AT COMPLETION OF CONSTRUCTION , PRIOR TO BACKFILLING, THE
, O
BOARD OF HEALTH SHALL BE NOTIFIED FOR INSPECTION.
PITCH ALL SEWER LINES 1/4" / FT. UNLESS INDICATED
����• SAID OTHERWISE.
.9
�L ND G�ciO W "ER /Z NO G�,vD H'�7TFe
DESIGN DA TA
BEDROOMS -3 DISPOSAL
EST. TOTAL DAILY EFF _ 330
GALS.
LEGEND — SEPTIC TANK /oD0 GAL.
SIDEWALL AREA 2.5 GAL./SO. FT.
BOTTOM AREA �- /,o GAL./SQ. FT. SEWAGE D/ �O��� �,vIS� �
oXoc� EXISTING GRADE LEACHING REQUIRED /�.3, e39 SQ.FT.
ZONE ____ -/
0 00� FINISHED GRACE ACTUAL LEACHING AREA 2,5l.5/ SQ.FT. FOR
Jr-
C3 . oo INVERT ELEVATION
DOMESTIC WATER SOURCE Toww W.gTE'k' ; _
-- --- - PROPERTY LINE
PLAN REFERENCE
MEAN HIGH WATER SCALE' AS INDICATED DATE S 24 g
BENCH MARK DATUM: U3G,5 /929 M.SL OATurn w : _ MARSH ' WM M. WIJRW/CK B ASSOCIATES
i
Z BOX 801 - NORTH/ FALMOLITH
o�c�'E .vv�v- ,�.f,4 z,�,E o "�' � �` Ml3SSAC RUSE T TS 02556