HomeMy WebLinkAbout0019 ROSEMARY LANE - Health 19 Rosemary Lane
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COMMONWEALTH OF MASSACHUSETTS MAY 1 9 2004
EXECUTIVE OFFICE OF ENVIRONMENTAL AFF RS
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TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 19 ROSEMARY LANE CENTERVILLE 02632 � � —on l�
Owner's Name: MOLLY FEDELE
Owner's Address: 19 ROSEMARY LANE CENTERVILLE 02632
Date of Inspection: 4/22/04
Name of Inspector: (please print) JOHN GRACI,INC.
Company Name: SEPTIC INSPECTIONS
Mailing Address: P.O.BOX 2119 TEATICKET,MA.02536
Telephone Number: 508-564-6813 FAX 508-564-7270
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 the inspection.The inspection was performed based on my training and
experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system
inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
X Passes
_ Conditionally a es
_ Needs Furthe aluation by the Local Approving Authority
Fails
Inspector's Signature: Date: 4/22/04
The system inspector shall submit a py of this inspection report to the Approving Authority(Board of Health or DEP)within
30 days of completing this inspectio . If the system is a shared system or has a design flow of 10,000 gpd or greater,the
inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be
sent to the system owner and copies sent to the buyer, if applicable, and the approving authority.
Notes and Comments
SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE
SYTEM'S USEFUL LIFE.
****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.
Title 5 Tncnartinn Fnrm 6/1 50000 1
Page 2.,of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 19 ROSEMARY LANE CENTERVILLE 02632
Owner: MOLLY FEDELE
Date of Inspection: 4/22/04
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310
CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
SYSTEM PASSED TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG
THE SYTEM'S USEFUL LIFE.
B. System Conditionally Passes:
_ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,
upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain.
n/a 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.
ND explain: n/a
n/a 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
_ obstruction is removed
_ distribution box is leveled or replaced
ND explain: n/a
n/a 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
_obstruction is removed
ND explain: n/a
Page 3-of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 19 ROSEMARY LANE CENTERVILLE 02632
Owner: MOLLY FEDELE
Date of Inspection: 4/22/04
C. Further Evaluation is Required by the Board of Health:
_ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to
protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is
not functioning in a manner which will protect public health,safety and the environment:
_ Cesspool or privy is within 50 feet of a surface water
_ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water
supply or tributary to a surface water supply.
_ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
_ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water
supply well".Method used to determine distance n/a
"This system passes if the well water analysis,performed at a DEP certified laboratory, 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 nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy
of the analysis must be attached to this form.
3. Other:
n/a
Page 4 Qf 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 19 ROSEMARY LANE CENTERVILLE 02632
Owner: MOLLY FEDELE
Date of Inspection: 4/22/04
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all-inspections:
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged
SAS or cesspool
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool
X Liquid depth in cesspool is less than 6"below invert or available volume is less than Y2 day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times
pumped 3 MONTHS AGO PER OWNER.
X Any portion of the SAS,cesspool or privy is below high ground water elevation.
X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool or privy is within a Zone 1 of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
X 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 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 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.]
NO (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in
310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary to a surface drinking water supply
X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat
under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
a
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 19 ROSEMARY LANE CENTERVILLE 02632
Owner: MOLLY FEDELE
Date of Inspection: 4/22/04
Check if the following have been done. You must indicate "yes" or"no"as to each of the following:
Yes No
X _ Pumping information was provided by the owner,occupant,or Board of Health
X Were any of the system components pumped out in the previous two weeks?
X _ Has the system received normal flows in the previous two week period?
X Have large volumes of water been introduced to the system recently or as part of this inspection ?
X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
X _ Was the facility or dwelling inspected for signs of sewage back up?
X _ Was the site inspected for signs of break out?
X _ Were all system components,excluding the SAS, located on site
X _ 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?
X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance
of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
X _ Existing information. For example,a plan at the Board of Health.
X _ 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(3)(b)]
S
Page 6 cif 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 19 ROSEMARY LANE CENTERVILLE 02632
Owner: MOLLY FEDELE
Date of Inspection: 4/22/04
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):330
Number of current residents:3
Does residence have a garbage grinder(yes or no): NO
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no): NO
Seasonal use: (yes or no): NO
Water meter readings, if available(last 2 years usage(gpd)): fig
Sump pump(yes or no): NO
Last date of occupancy: n/a 0
COMMERCIAL/INDUSTRIAL
Type of establishment: n/a
Design flow(based on 310 CMR 15.203): n/agpd
Basis of design flow(seats/persons/sqft,etc.): n/a
Grease trap present(yes or no): NO
Industrial waste holding tank present(yes or no): NO
Non-sanitary waste discharged to the Title 5 system(yes or no): NO
Water meter readings, if available: n/a
Last date of occupancy/use: n/a
OTHER(describe): n/a
GENERAL INFORMATION
Pumping Records
Source of information:3 MONTHS AGO PER OWNER
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: n/agallons--How was quantity pumped determined?n/a
Reason for pumping: n/a
TYPE OF SYSTEM
X 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)
_Tight tank Attach a copy of the DEP approval
Other(describe): n/a
Approximate age of all components,date installed(if known)and source of information:
1999 PER ASBUILT
Were sewage odors detected when arriving at the site(yes or no): NO
h
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 19 ROSEMARY LANE CENTERVILLE 02632
Owner: MOLLY FEDELE
Date of Inspection: 4/22/04
BUILDING SEWER(locate on site plan)
Depth below grade:22"
Materials of construction:_cast iron X40 PVC_other(explain): n/a
Distance from private water supply well or suction line: n/a
Comments(on condition of joints,venting,evidence of leakage,etc.):
TOWN WATER
SEPTIC TANK:X(locate on site plan)
Depth below grade: 16"
Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a
If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate)
Dimensions: L 8' 6" H 5' 7" W 4' 10""
Sludge depth: n/a
Distance from top of sludge to bottom of outlet tee or baffle: n/a
Scum thickness: n/a
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: n/a
How were dimensions determined: MEASURED
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.
RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE.
GREASE TRAP:_(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
Date of last pumping: n/a
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
n/a
7
Page 8 of l l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 19 ROSEMARY LANE CENTERVILLE 02632
Owner: MOLLY FEDELE
Date of Inspection: 4/22/04
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Capacity: n/a gallons
Design Flow: n/a gallons/day
Alarm present(yes or no): N/A
Alarm level: N/A Alarm in working order(yes or no): NO
Date of last pumping: n/a
Comments(condition of alarm and float switches,etc.):
n/a
DISTRIBUTION BOX:X(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE
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.):
THERE ARE TWO D-BOXES BOTH STRUCTURALLY SOUND.
PUMP CHAMBER:_(locate on site plan)
Pumps in working order(yes or no): NO
Alarms in working order(yes or no):NO
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
n/a
R
Page 9 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 19 ROSEMARY LANE CENTERVILLE 02632
Owner: MOLLY FEDELE
Date of Inspection: 4/22/04
SOIL ABSORPTION SYSTEM(SAS): _ (locate on site plan,excavation not required)
If SAS not located explain why:
n/a
Type
1000 GAL 6' X 6' leaching pits, number: 1
INFILTRATORS leaching chambers, number: 4
n/a leaching galleries, number: n/a
n/a leaching trenches, number, length: n/a
n/a leaching fields, number: n/a
n/a overflow cesspool, number: n/a
n/a innovative/alternative system
Type/name of technology: n/a
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.):
THE LEACH FIELD IS FUNCTIONING PROPERLY.THE INFILTRATORS HAVE 4' OF STONE-BOTTOM IS
AT 4'-FIELD SHOWED NO SIGNS OF FAILURE-SOIL PROBED DRY.
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: n/a
Depth—top of liquid to inlet invert: n/a
Depth of solids layer: n/a
Depth of scum layer: n/a
Dimensions of cesspool: n/a
Materials of construction: n/a
Indication of groundwater inflow(yes or no): NO
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
PRIVY: (locate on site plan)
Materials of construction: n/a
Dimensions: n/a
Depth of solids: n/a
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
4
I
Page 19 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 19 ROSEMARY LANE CENTERVILLE 02632
Owner: MOLLY FEDELE
Date of Inspection: 4/22/04
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch 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.
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Page I 1 of I 1
0
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 19 ROSEMARY LANE CENTERVILLE 02632
Owner: MOLLY FEDELE
Date of Inspection: 4/22/04
SITE EXAM
_Slope
_Surface water
_Check cellar
Shallow wells
Estimated depth to ground water 10+feet
Please indicate(check)all methods used to determine the high ground water elevation:
NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a
YES Observed site(abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board of Health-explain: n/a
NO Checked with local excavators, installers-(attach documentation)
NO Accessed USGS database-explain: n/a
You must describe how you established the high ground water elevation:
GROUNDWATER DETERMINED FROM HAND AUGER- 10+FEET
c TOWN OF BARNSTABLE
LOCATION -1 C� ,t�nt_r e/ C .T'�i SEWAGE #
VILLAGE �1
—`y�`t�1 �� ASSESSOR'S MA/P LOT "�
1 INSTALLER'S NAME&PHONE NO. U
SEPTIC TANK CAPACITY Q 7C 1 St (,0W n Z0>C
LEACHING FACELM: (type) (size) I C
NO. OF BEDROOMS Ckrw`(c) U
BUILDER OR OWNER
PERMTTDATE: f l II I ft COMPLIANCE DATE: .
Separation Distance Between the:
i
Maximum Adjusted Groundwater Table to the 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 facility) Feet
Furnished by
A Qi6� 3 c/s Q Qou �x15�
y- x
o
61 Zv,
i
e
TOWN OF BARNSTABLE c�'
LOCATION C? IkAe r-,( C SEWAGE #
M
VILLAGE ASSESSOR'S MAP 4 LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY Q X l Sk L®t . 1'-->Z-O)WI,
LEACHING FACILITY: (type) Q �e1(�-k6 (size) FY 6t"4-,
NO. OF BEDROOMS Ctr'Ovg0
BUILDER OR OWNER
PERMIT DATE: f 1 Q. ��COMPLIANCE DATE: .
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist r
on site or within 200 feet of leaching facility) 1" Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
t io
p1i
L( K
e� -):
No. �( Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
ZippYication for Digooar *pgtem Congtruction Permit
Application for a Permit to Construct( )Repair(- )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. tc, Owner's Name,Address and Tel.No.
Assessor's Map/Parcel (JL~ ✓d/i �e 5
`y�- C*7—
Installer's Name,Address,and
d�{Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder )
Other Type of Building No. of Persons Showers( ) .Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank ®t�6 CsG.(_ P.X1SA Type of S.A.S.
Description of Soil
Nature of Repai or Alterations(Answer when app t'cable)_Ad T n�,kfiy,,Jskrs W
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Envir rental Code and not to place the system in operation until a Certifi-
cate of Compliance has been ' �sud by this Bo of ealth. l Q
Signed )NlDate
Application Approved by Date Z
Application Disapproved for the following reaso
Permit No. `Z Date Issued z3
M.
No. / /1 / "f i VV Fee 50 c /
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ✓
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
Zipphcation for 3igpoml *pgtem.-.,, Co-ngtruction 3permit —00
Application for a Permit to Construct( )Repair Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address 1.or Lot No. `c, Owner's Name,Address and Tel.No.
GS M7 ..J
Assessor's Map/Parcel i o � e S ( -
\4�- op _
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder)
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow ,*"� gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank 1_pPg G/- _yperof S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) s�-�
a %J%,d-err
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been ' d by this Bo d o ealth. r
Signed Date �2
Application Approved by A 4 Date 2
Application Disapproved for the following reaso
Permit No. �J -'7 c, 0 Date Issued �—Z�- 9 9
---------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
�{1- 0 o1 BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired ( ( Upgraded( )
Abandoned( )by a .��_S 4 r�)C- r
at k A has been constructed in accordance
with the provisions o Title_5 and thTfor Disposal System Construction Permit No.!3!R 0 dated //_ 3-9 9
Installer Designer ]
Tj
The issuance of this pe t shall no bee strued as a guarantee that the sy Wm will function as igne�d
Date Inspector _
r�-- ,.
1
No. '_ '?/ � -------------------------——Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
30igpogal 6pgtem Congtruction Permit
Permission is hereby granted to Construct( )Repair(L114upgrade( )Abandon( )
System located at g CZ 6C&
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permit.
Date: nlZ- 2 3-9l Approved by
1: 1i6i99
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
CERTIFICATION OF SKETCH :AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PER UT (WITHOUT DESIGNED PLANS)
hereby certizy that the application for disposal works
construction permit sited by me dated t ` ac� '�fT_ cone.—M'nQ the
property located at —, meets all of the
following criteria: C
• The failed system is conner ed to a residential dwelling only. There are no commercial or business
uses associated with the dwelling. `7
• The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch.
• There are no wetlands within 100 feet of the proposed septic system
• There are no private wets within 130 feet of the proposed septic system
• There is no increase in flow and/or change in use proposed
• There are ao variances requested or needed.
• The bottom of the proposed leaching facility will not be located less than five feet above the
ma..dmum adjusted groundwater table elevation. [Adjust the z-oundwater table using the Frimpior
method when applicable]
• If the S.A.S. will be located with 250 fee:of any vegetated wetlands, the bottom of the proposed
leaching facility will not be located less than founeen(14) feet above the ma.,imum adjusted
groundwater table elevation,
Please complete the following:
A) Too of Ground Surface cievation(using GIS information)
B) G.W. Elevation
30—_the High G.W. Adjustment .�o� __ 3
DF EcRENCE 3ETW-E-7N a.and 3
(D SIGNED DATE:
(Sketch proposed plan of system on backl.
u::u31eh Colder.cat
CA
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS John Grad
DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector
ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119
TeaTicket,Ma.
(508)564-6813
TRUDY COXE
Secretary
ARGEO PAUL CELLUCCI r t; DAVID B.STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION ,
Property Address: 19 ROSEMARY LANE CENTERVILLE MAP 147 PAR 007 L 2
Name of Owner JIM RIODRDAN
Address of Owner: SAME
tip
Date of Inspection: 10/30/99
Name of Inspector:(Please Print)JOHN GRACI b
P 1999
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)
Company Name: n/a �
Mailing Address: nla
Telephone Number: n/a
s
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:
_ Passes The inpection Is based on criteria defined In Title V
Conditionally Passes code 310 CMR 15.303.My findings are of how the system is
_ Needs Further Evaluatio By the Local Approving Authority performing at the time of the Inspection.My Inspection does
X Fails not Imply any warranty or guarantee of the longgevity of the
septic system and any of Its components useful life.
Inspector's Signature: � Date:11/1/99
The System Inspector shall bmit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of
completing this inspection.if the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner
shall submit the report to the appropriate regional office of the Department of Environmental Protection.The original should be sent to the
system owner and copies sent to the buyer,if applicable,and the approving authority.
NOTES AND COMMENTS
THE SYSTEM SSES TLE V INSPECTION. THE LEACH PIT IS PAST THE EFFECTIVE DEPTH OF LEACHING.THE PIT HAD.NO VISABLE
LEACHING LEFT E TIME OF THE INSPECTION.
revised 9/2198 Page 1 of 11
a
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 19 ROSEMARY LANE CENTERVILLE MAP 147 PAR 007 L 2
Owner: JIM RIODRDAN
Date of Inspection:10/30/99
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
_ I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated
are indicated below.
COMMENTS:
n/a
B. SYSTEM CONDITIONALLY PASSES:
One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the
replacement or repair,as approved by the Board of Health,will pass.
Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not.
Wa The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or
the septic tank,whether or not metal,is 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 complying septic tank as
approved by the Board of Health.
n/a 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
nta 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
revised 9/2198
Page 2 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 19 ROSEMARY LANE CENTERVILLE MAP 147 PAR 007 L 2
Owner: JIM RIODRDAN
Date of Inspection:10/30/99
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety
and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS
NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of surface water
Cesspool or privy 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 ANY)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 feet of a surface water supply or tributary to a
surface water supply.
r.
The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
_ r
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 than 100 feet but 50 feet or more from a
private water supply well,unless a well water analysis 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 nitrogen is equal to or less
than 5 ppm,Method used to determine distance nh(approximation not valid).
3) OTHER
Wa
revised 9/2198
Page 3 of 11
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 19 ROSEMARY LANE CENTERVILLE MAP 147 PAR 007 L 2
Owner: JIM RIODRDAN
Date of Inspection:10/30/99
D. SYSTEM FAILS:
You must indicate either"Yes"or"No"to each of the following:
X I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is
identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
X Backup of sewage Into facility or system component due to an overloaded or clogged SAS or cesspool.
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool.
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow,
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped n1a.
X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
X Any portion of a cesspool or privy Is within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool or privy is within a Zone I of a public well.
X Any portion of a cesspool or privy,is within 50 feet of a private water supply well,
X 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.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic ompounds,
ammonia nitrogen and nitrate nitrogen.
The liquid level In the SAS is over the invert pipe,is in Hydraulic Failure.
E. LARGE SYSTEM FAILS:
You must indicate either"Yes"or"No"to each of the following:
The following criteria apply to large systems in addition to the criteria above:
_ The system serves a facility with a design flow of 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:
Yes No
X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary to a surface drinking water supply
X 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 upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the
Department for further information.
revised 9/2198 Page 4 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 19 ROSEMARY LANE CENTERVILLE MAP 147 PAR 007 L 2
Owner: JIM RIODRDAN
Date of Inspection:10/30/99
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
Yes No
X Pumping information was provided by the owner,occupant,or 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 that 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 Soil Absorption System,have been located on the site.
X 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 Soil Absorption
. System on the site has been determined based on:
X Existing information,For example,Plan at B4O,H,
X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)
[1 5.302(3)(b))
X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of
Subsurface Disposal Systems.
revised 9/2198 Page 5 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 19 ROSEMARY LANE CENTERVILLE MAP 147 PAR 007 L 2
Owner: - JIM RIODRDAN
Date of Inspection:10/30/99
FLOW CONDITIONS
RES113ENTIAl:
Design flow:-Q g.p.d./bedroom
Number of bedrooms(design): 3 Number of bedrooms(actual):$
Total DESIGN flow: =
Number of current residents:A
Garbage grinder(yes or no):NQ
Laundry(separate system)(yes or no): NO If yes,separate inspection required
Laundry system inspected(yes or no):M
Seasonal use(yes or no):.NQ
Water meter readings,if available(last two year's usage(gpd): I]/a
Sump Pump(yes or no): NQ
Last date of occupancy: n1a
COM M ERCIAL/INDUSTRIAL
Type of establishment: n&
Design flow: n[A gpd(Based on 15.203)
Basis of design flow: n1a
Grease trap present:(yes or no):JLQ
Industrial Waste Holding Tank present:(yes or no): NO
Non-sanitary waste discharged to the Title 5 system:(yes or no):No
Water meter readings.if available:n/a
Last date of occupancy: n&
OTHER: (Describe)
WA
Last date of occupancy: n&
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as part of inspection:(yes or no):NQ
If yes,volume pumped W& gallons
Reason for pumping: n1a
TYPE OF SYSTEM
X 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)
I/A Technology etc.Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other: nla
APPROXIMATE AGE of all components,date installed(if known)and source of information:
THE SYSTEM IS 11 YEARS OLD PERMIT#98-968
Sewage odors detected when arriving at the site:(yes or no). NQ
revised 9/2/98 Page 6 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 19 ROSEMARY LANE CENTERVILLE MAP 147 PAR 007 L 2
Owner: JIM RIODRDAN
Date of Inspection:10/30/99
BUILDING SEWER:
(Locate on site plan)
Depth below grade: Z
Material of construction:_ cast iron X 40 PVC _ other(explain)
Distance from private water supply well or suction line: TOWN
Diameter: nfa
Comments: (condition of joints,venting,evidence of leakage,etc.)
Wa
SEPTIC TANK: X
(locate on site plan)
Depth below grade: 2:
Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain)
nta
If tank is metal,list age is age confirmed by Certificate of Compliance(Yes/No): XG
n/a
Dimensions: L 10'6"H 6'7"W 4'10"
Sludge depth: 1'
Distance from top of sludge to bottom of outlet tee or baffle: 2X
Scum thickness:-a
Distance from top of scum to top of outlet tee or baffle:
r Distance from bottom of scum to bottom of outlet tee or baffle: A
How dimensions were determined: MEASURED
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.)
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND EVERY TWO YEARS.
a
4 GREASE TRAP:
(locate on site plan)
Depth below grade: '
Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain)
nLa
Dimensions: n&
Scum thickness: nfa
Distance from top of scum to top of outlet tee or baffle:J)&
Distance from bottom of scum to bottom of outlet tee or baffle Wa.
Date of last pumping: Wa
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.)
DIA
revised 9/2198 Page 7 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 19 ROSEMARY LANE CENTERVILLE MAP 147 PAR 007 L 2
Owner: JIM RIODRDAN
Date of Inspection:10/30/99
TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection)
(locate on site plan)
Depth below grade: nLa
Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain)
n&
Dimensions: nLa
Capacity: WA gallons
Design flow: n& gallons/day
Alarm present: NQ
Alarm level:jV& Alarm in working order:Yes_No—: NQ
Date of previous pumping: nLa
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
nLa
DISTRIBUTION BOX: _
(locate on site plan)
,Depth of liquid level above outlet invert:nLa
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.)
.r
PUMP CHAMBER: NQ
(locate on site plan)
Pumps in working order:(Yes or No): NQ
Alarms in working order(Yes or No): NQ
Comments:
(note condition of pump chamber,condition of pumps and appurtenances.etc.)
nLa
revised 9/2/98 Page 8 of 11
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 19 ROSEMARY LANE CENTERVILLE MAP 147 PAR 007 L 2
Owner: JIM RIODRDAN
Date of Inspection:10/30/99
SOIL ABSORPTION SYSTEM(SAS): X
(locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods)
If not located,explain:
nLa
Type:
leaching pits,number: 1000 GALLON LEACH PIT
leaching chambers,number: _D&
leaching galleries,number: _nLa
leaching trenches,number,length: n&
leaching fields,number,dimensions: 11La
overflow cesspool,number: nLa
Alternative system: nLa
Name of Technology: -nLa
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.)
THE LEACH PIT IS PAST THE EFFECTIVE DEPTH OF LEACHING,THE LIQUID LEVEL IS OVER THE PIPE,AND THERE WAS NO LEACHING LEFT.
CESSPOOLS: _
(locate on site plan)
'Number and configuration: nla
Depth-top of liquid to inlet invert: Wa
`Depth of solids layer: Wa
Depth of scum layer. nla
y Dimensions of cesspool: Wa
Materials of construction: nla
Indication of groundwater: nta inflow(cesspool must be pumped as part of inspection)n&
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
PRIVY: _
(locate on site plan)
Materials of construction:n& Dimensions:n(a
Depth of solids: n&
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
n&
revised 9/2/98 Page 9 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIO14 FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 19 ROSEMARY LANE CENTERVILLE MAP 147 PAR 007 L 2
Owner: JIM RIODRDAN
Date of Inspection:10/30/99
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
n/a
revised 9/2198 Page 10 of 11
J
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 19 ROSEMARY LANE CENTERVILLE MAP 147 PAR 007 L 2
Owner: JIM RIODRDAN
Date of Inspection:10/30/99
NRCS Report name: nLa
Soil Type: nta
Typical depth to groundwater: nLa
USGS Date website visited: n&
Observation Wells checked: XG
Groundwater depth:Shallow _ Moderate _ Deep _
SITE EXAM _ Slope
_ Surface water
_ Check Cellar
Shallow wells
Estimated Depth to Groundwater 12 Feet
Please indicate all the methods used to determine High Groundwater Elevation:
_ Obtained from Design Plans on record
_ Observed Site(Abutting property,observation hole,basement sump etc.)
_ Determined from local conditions
Checked with local Board of health
. Checked FEMA Maps
_ Checked pumping records
_ Checked local excavators,installers
7.
* XUsed USGS Data
Describe how you established the High Groundwater Elevation.(Must be completed)
USGS MAPS AND CHARTS
revised 9/2198 Page 11 of 11
l
TOWN OF BARNSTABI.R
!�Ira r!r" Xlewe
LC)CAT1_ON LOB —.LLZX ^�A U, __—SEWAGE #
VILLAGE C tWJ t l ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO._ t kQf---LY—C�r�_J5G _--
SEPTIC TANK CAPACITY_�UO
Q,LEACHING FACILITY:(type)�� 1,00 (size a.J
NO. OF BEDROOMS Z- PRIVATE'WE OR PUBLIC WATE
GUILDER, OR OWNER_
DATE PERMIT ISSUED:__ #ZZ,�
DATE COiWLIANCE ISSUED_ IL_
VARIANCE GRAN'PED: —��,_—
. .
.�8' a ��
��"3
�.�
3`�
,, �"�
a�$• � ..
No"
THE COMMONWEALTH ,OF MASSACHUSETTS
BOARD OF HEA TH
..............
Appliration for Uhipaiial lgorkg Tonstrurtion Famit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at:
......................J�.�jo -if............ez.-11......................4��.ee .......ez
Add or Lot No.Location �__X-
C ;
....7.0..........42;e No. /12 ---------_
caner Address X.
.............................. ........ ..........................................................................................
Insfaller Address
U Type of Building Size L.ot..//k;�----Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic Garbage-Grinder ( )
04 Other—Type of Building ............................ No. of persons......................_._... Showers Cafeteria ( )
Otherfixtures .............................................................................................................3.2..... .......................
Design Flow............................................gallons per person per day. Total daily flow.___.._....... ... __.......gallons.
1:4 Septic Tank—Liquid capacity/0204.gallons Length................ Width._............__ Diameter._._.__..._..._. Depth...._...__..__..
Disposal Trench—No Width.................... Total Length.__......._......... Total leaching area-,$__'�1z.2.7sq. ft.
Seepage Pit No.---__-_--_ Diameter.................... Depth below inlet___..._..____._____ Total leaching area..................sq. ft.
Other Distribution box Dosing tar:��
Percolation Test Results Performed by._......_... ..4 4arh......6w..<................. Date........../---/---
Test Pit No. I minutes per inch Depth of Test Pit.... Depth to ground water....... . ...
Test Pit No. 2................minutes per inch Depth of Test Pit._...........___.... Depth to ground water..__.._____.___
P
.............................................................................................................................................................
0 Description of Soil------------------..S i�t......t....... �.G. �. ......... ----- ---- ------------ ..........................................................
U ................................................. ... . ....Z;....... ... .. _ .. ............................................. ...............................
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
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 I I:M, 5 of the State Sanitary Code—Tqie under'si ed - ther agrees not to place the system in
operation until a Certificate of Compliance has been issu y t b o alt
Signed... ....... .......0..... ................ ............................. ...... .
........... .. ... ........ .. .......... ........�/ t
Application Approved By.
to
gned-_
_S-i .......... k/at
Application Disapproved for the following r ds ns:............. ...............................................................................................
............................................................................................................................................................. ...........................................
2,6 — Date
Permit No...... . ....... Issued_.......................................................
Date
• �r T 4 � '
� i V
No.. ��
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Appliratioat for Uiopooa1 Vorkii Tonfitrurtion Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
...................... ..�i......t/a ....... .................................................
Location Add ess -. or Lot No
Owner Address
a ...... �. ------- c ,,t_ is_ i � ---------------------------------- ....----------•.
� In alley Address .-f•�
Type of Building Size Lot__,��e-1_ ____Sq. feet
---------------
Dwelling No. of Bedrooms.............:..�x ____.__..__..._.Ea Expansion Attic a g— p ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
Q Other fixtures ----------------------------•-------------------•-•---•-•••-•••••-••-•-••--•••---•----•--•-•••-----••-•-•--
----•--•--
W Design Flow___________________________________________gallons per person per day. Total daily flow.............. '___: . ._...........gallons.
WSeptic Tank—Liquid capacity o c_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 ( ) Dosing tank
Percolation Test Results Performed b _. ...... _..__. ' ................. Date.........
_4 ._.minutes per inch Depth of Test Pit___ ;: ;�_"_ Depth to ground water_.._____ ____ ________
,.� Test Pit No. 1._,::._. ___ ��� r f14 Test Pit No. 2............... per inch Depth of Test Pit____________________ Depth to ground water..__._...__.___._..___.
Ix .••----••••--•-•-----•••--•••--••-••-•••-••-•••-•---•-••-•----••-••••----••-•••......--••--.._..._............-••••-••-•--•••-------••--••••.............•--
0 Description of Soil............................................-- j�am`...... •---•--•-•-
txj -----------------------------------------•--------- '�' ......: -' ` sw........................................................................................ -
W
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 i''L
p 5 of the State Sanitary Code—T e undersi ed • .tl er agrees not to place the system in
operation until a Certificate of Compliance has been is y t b d o eal
Signed._ .____ _ _____
Application Approved By_ __ __________.................. _ .. ,.............. q
ate
Application Disapproved for the following r as ns:--••___________________•---•--•-----•----••------••----•--•---•--•----•-----...................................
--•••._...._...-•-----••••••-----•-•-------•-•-••-•-••-•-•-•••••-•••__.__..••--•--•......-•---•-•---••---•-•--•_•-•-_._...-•-•-•••-••••••-•------••-------•-------- ------------•------.............
Date
Permit No.--•- _ Issued_.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
OARD F' H��A�"TH
.........../D .oF....... ..... .... �C,I[.Y.��/�.... ......
�rrifirtt#e of faoutgiaatrr
THY" lI T TIFY, That the Individual Sewage Disposal System constructed X) or Repaired ( )
by_....... +�1-� -------__ __a--------------------
------•--
at
has been installed in accordance with the provisions of TI TQQ/� of The to Sanitary sad jibed in the
application for Disposal Works Construction Permit No �7._• dated_.._. ..
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A G ARA TEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS 1'
1_,� BOARD O jEE41 �,�.
...........roV.-v(..V.......-OF........... �....£/ ...,��....../
N ..9 y
Disposal 0 W aaotr ionVirrutit
y g -1�/ / ... ..
Permission t ereb ranted.------ . !-_.._---- -•----------------------------------------------=>•-----------...---------••----..._........---..._
to Constru t Re air n In��d.i�vii S Di em
atNo........ ...-- ------Ft
Streetas shown on the appli tion for Disposal Works Construc eerymitN ... __ _ ated... � U_ _ __________
-- ..... •.A '1 ------- -- ------- --- ------•-- • - ___---•------••-
DATE. Board o£ Heath
------•------•------ 5
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
I
SECTION - SEWAGE
TO oF- C.E. @ S.E. C co I REF'
1)JTE�. OF �OSEi�iF;�Y L F;
' - SEPTIC TANK - - "D"BOX - -, -LEACH
TOP E�F FON
`=��•• (MSL)t r- '.2"OF 118TO I/,"
WASHED STONE
i r _
96 oq
TF '` q4 80
1 q� 4�3 -z o
AS
IN i Q
�-- OUT- IN14
• _..__�....._.. ..
'SEPTICG ' i `�-�_
/ ! TANK 1_-~ �...^�,• Ii/�
ELEV. ELEV. ELEV. ELEV.
2 E
ELEV. ELEV._ 2 I ,
I
D t I1
r
1
1 M:'•
S e 1 �
L{,5 WASHED STONE—� � '3 l
d�
Or-f"2 �=
lT�0 GP,1` 2 5'�
TEST HOLE LOG _ eL
CD
TEST BY
Lt� I 3 �iC:'y 3 _ trv, Gl LOT. I
�.Falrbo.r,l� t�
WITNESS �y �WC•� - 6
TEST DATE DESIGN v BEDROOM HOUSE N , "`T•F. S{ O
c N
T.H. 1 T.H. rx 2 p -o '
- It ELEV. ELEVf# NO
i-01•t 2� rjp• } ;r t LZ DISPOSER DISPOSER _
5oi PERC RATE MINAN.
su
48• r S D ,(+„p FLOW RATE 3?Ip (GAL/DAV) 3 �O
cl c SEPTIC TANK,5p X (15)- \ Q°�
MED �A REQ'D SEPTIC TANK SIZE
b;
''N'-' YDi Er' LEACH FACILITY
SIDE WALL 105?c' = !E?r`.`.s (2 1 �`i71.L. G/D. '; LOT a
BOTTOM )p2�r'/G = 7G .O ) r)6 G/D.
156 Z-7 (1 TOTAL 2G';.o S.-V _ �q9•`7 Gf C' �- 1Cn Cyr `�j
/
USE: O(�1� LEACHING '� 100 . OCt ' _, V — —
/V 1-/ WATER ENCOUNTERED 1 0
NOTES: (UNLESS OTHERWISE NOTED)
OF
_.DATUM(MSQ_TAKEN FROM _ �_QUADRANGLE MAP ��� � I 1 ,•;<,
2.MUNICIPAL WATER _l�� AVAILABLE
3.PIPE PITCH:Mill PER FOOT ARNE H. G "
4.DESIGN LOADING FOR ALL PRECAST UNITS:AASHO• -44 �0 OJALA �„�' i ` , ,Q
S.MIN.GROUND COVER OVER ALL SEWAGE FACILITIES:(1)FT. �- CIVIL H W/ 1�{C
.
6.PIPE JOINTS SHALL BE MADE WATER TIGHT NO. 3079? 0^� ffrr
7.CONSTRUCTION DETAILS TO BE ACCORDANCE WITH COMM.OF MASS.
STATE ENVIRONMENTAL CODE TITLES t� p�`� dfgs�� LOCUS: LOT 2 c� • ANd�A
yJ
n�
FINE N�
REG.PROFESSIONAL ENGINEER iv OJALA
I ;s o2C34F ?' REF: L07
down cape engineering PREPARED FOR:
CIVIL ENGINEERS 4 �A
LAND SURVEYORS
BOARD OF HEALTH an Nah� REG.LAND SU VEYOR ALE II` 8
CONTOURS (EXISTING)............. APPROVED DATE BH�NS?A��E,MAw(IIr.W 1 1 3 .`j� �E ��2.
4O
DATE
(PROPOSED)-�-O-O'�-