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HomeMy WebLinkAbout0116 SHEAFFER ROAD - Health 116 Sheaffer Road, Centerville r—A = 172 - 027 No. 42101/3 ORA c� ESSELTE 10% 0 0 e 0 0 R7BARNSTABLE D SE00 COMMONWEALTH OF MASACHUSETTS sT EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS T�WT. DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET BOSTON MA 02108(617)292-3500 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 116 SHEAFFER RD CENTERVILLE, MA 02632 M172 P027 L32 Name of Owner GEORGE ALLAIN Address of Owner: 116 SHEAFFER RD CENTERVILLE,MA 02632 Date of Inspection: 9/11/00 Name.of Inspector: JOHN GRACE 1 am a DEP approved system inspector pursuant to Secdon 15.340 of Tltle 5(310 CMR 15.000) Company Name: SEPTIC INSPECTIONS Mailing Address: P.O.BOX 2119 TEATICKET,MA.02636 Telephone Number: 608-664-6813 FAX 508-664-7270 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 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: X Passes _ Conditionally Passes _ Needs Further Evaluati By the Local Approving Authority Fails �i Inspector's Signature: L Date:9/11/00 The System Inspector shall sub t a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of completing this inspection.If th 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 inspection is based on criteria defined in Title V code 310 CMR 15.303.My findings are of how the system is performing at the time of inspection.My inspection does not imply any warranty or guarantee of the longevity of the septic system and any of its component's useful life" THE SYSTEM PASSES TITLE V INPECTION.RECOMMEND PUMPING THE EVERY TWO YEARSTO-PROLONG-THE SYSTEM'S USEFULL LIFE. RECOMMEND RAISING ALL COVERS TO THE SYSTEM. ? RECEIVE� SEP 2 2 2000 TOVA OF BARNsTAdt£ HEA.HDEPT. f l revised 9/2J98 Page 1 of 11 \� e.i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 116 SHEAFFER RD CENTERVILLE, MA 02632 M172 P027 L32 Name of Owner GEORGE ALLAIN Date of Inspection: 9/11100 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: X 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. 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. n/A 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 n& The required system re y q 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 9/2/98 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 116 SHEAFFER RD CENTERVILLE, MA 02632 M172 P027 L32 Name of Owner GEORGE ALLAIN Date of Inspection: 9/11/00 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. _ The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply 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 than 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 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 n&(approximation not valid). 3) OTHER ' n/a revised 9/2198 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 116 SHEAFFER RD CENTERVILLE, MA 02632 M172 P027 L32 Name of Owner GEORGE ALLAIN Date of Inspection: 9/11100 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: 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 Wa. 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;#thin 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 compounds, ammonia nitrogen and nitrate nitrogen. 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 Arinking water supply X the system is within 200 feet of a tributarytto 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 9098 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 116 SHEAFFER RD CENTERVILLE, MA 02632 M172 P027 L32 Name of Owner: GEORGE ALLAIN Date of Inspection: 9/11/00 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)j X _ The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. t>: r, revised 9/2/98 Page 5 of 11 ;. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 116 SHEAFFER RD CENTERVILLE, MA 02632 M172 P027 L32 Name of Owner GEORGE ALLAIN Date of Inspection: 9/11100 FLOW CONDITIONS RESIDENTIAL: Design flow: 110 g.p.d./bedroom Number of bedrooms(design): 3 Number of bedrooms(actual):n/a Total DESIGN flow: 330 gpd Number of current residents:3 Garbage grinder(yes or no):NO Laundry(separate 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 two year's usage): n/a gpd Sump Pump(yes or no): NO Last date of occupancy: n/a COM M ERCIAL/1NDUSTRIAL Type of establishment: n/a Design flow: n/a gpd(Based on 15.203) Basis of design flow: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: nla Last date of occupancy:n/a 1 OTHER: (Describe) n/a GENERAL INFORMATION PUMPING RECORDS and source of information: n/a System pumped as part of inspection:(yes or no):NO If yes,volume pumped n/a gallons 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) _ I/A Technology etc.Attach copy of up to date operation and maintenance contract _ Tight Tank Copy of DEP Approval Other:n/a APPROXIMATE AGE of all components,date installed(if known)and source of Information: 1997 §Mge odOR tle KIM WlteH 91fiuing At the§ite:(ye§aF fle). NO revised 9/2/98 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 116 SHEAFFER RD CENTERVILLE, MA 02632 M172 P027 L32 Name of Owner GEORGE ALLAIN Date of Inspection: 9111/00 BUILDING SEWER:X (Locate on site plan) Depth below grade: 30" Material of construction: _ cast Iron X 40 Pvc _ other(explain) Distance from private water supply well or suction line: n/a Diameter: n/a Comments: (condition of Joints,venting,evidence of leakage,etc.) THERE IS TOWN WATER SEPTIC TANK: X (locate on site plan) Depth below grade: 24" Material of construction: X concrete_ metal_ Fiberglass_ Polyethylene_ other explain: n/a If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NO Age: n/a Dimensions: 1600G L 10'6"H 6'6"W 6'8"" Sludge depth: 6" Distance from top of sludge to bottom of outlet tee or baffle: 28" Scum thickness: 2" 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 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.) THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. GREASE TRAP: _ (locate on site plan) Depth below grade: n/a Material of construction: _concrete_ metal_ Fiberglass _ Polyethylene_other Explain: Na 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: (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.) n/a revised 9/2/98 Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 116 SHEAFFER RD CENTERVILLE, MA 02632 M172 P027 L32 Name of Owner GEORGE ALLAIN Date of Inspection: 9/11/00 TIGHT OR HOLDING TANK: _ (Tank must be pumped prior to,or 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: NO Alarm level:N/A Alarm in working order:NO Date of previous pumping: n/a Comments: (condition of inlet tee,condition of alarm and float switches,etc.) n/a DISTRIBUTION BOX:X (locate on site plan) f: Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) THE DISTRIBUTION BOX IS 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 revised 9/2198 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 116 SHEAFFER RD CENTERVILLE, MA 02632 M172 P027 L32 Name of Owner GEORGE ALLAIN Date of Inspection: 9/11/00 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: n/a Type: leaching pits,number:(n/a)n/a ; leaching chambers,number: (2).2-500 GALLON DRYWELL CHAMBERS leaching galleries,number: (n/a)n/a leaching trenches,number,length: (n/a)n/a leaching fields,number,dimensions: (n/a)n/a overflow cesspool,number: (n/a)`n/a Alternative system: n/a 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 APPEARS TO BE FUNCTIONING PROPERLY,THE SYSTEM SHOWS NO SIGNS OF FAILURE.SOIL PROBED DRY IN LEACH AREA. CESSPOOLS: _ (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: n/a inflow(cesspool must be pumped as part of inspection)NO Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) nla 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 revised 9/2198 Page 9 of 11 u:d SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 116 SHEAFFER RD CENTERVILLE, MA 02632 M172 P027 L32 Name of Owner GEORGE ALLAIN Date of Inspection: 9111/00 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) �.� fmA AA �65 C At 3� bA D l` ec 1 d< _41 i revlsed 9/2/98 Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 116 SHEAFFER RD CENTERVILLE, MA 02632 M172 P027 L32 Name of Owner GEORGE ALLA1N Date of Inspection: 9/11/00 NRCS Report name: n/a Soil Type: n/a Typical depth to groundwater: n/a USGS Date website visited: n/a Observation Wells checked: NO Groundwater depth: Shallow_ Moderate_ Deep_ SITE EXAM _ Slope _ Surface water _ Check Cellar Shallow wells Estimated Depth to Groundwater 10 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 X Used USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) USGS MAPS AND CHARTS-10+FEET revised 9/2/98 Page 11 of 11 TOWN OF BAR/JNSTABLE C� LOCATION ��� Sh... �r� ` SEWAGE# r ' 20 VELLAGE 6P/J 7-r r V 4 Ile - ASSESSOR'S MAP&LOT L 6 r -U.)- 1/9 INSTALLER'S NAME&PHONE NO. `Y.t CI �Q` O L SEPTIC TANK CAPACITY Q I r LEACHING FACILITY: ( ) s �j��. (size) ta 2i S 7�NP NO'.OF BEDROOMS BUILDER OR OWNER y e 6 r Z2 114,� PER1viI TDATE: /fJ - 1 - K 7 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 fie g�t of leachin f cility) Feet Furnislied by l' �" LCy 000l 80 �/ 00r � � 7) 1 TOWN OF BARNSTABLE � -- _ LOCATION Z& JkeA fFe 1- /t a SEWAGE #16 ' �® �J / .'na r j V7,UAGE Crlj1-e ifs Ile, ASSESSOR'S MAP&LOT L i5r 13 - INSTALLER'S NAME&PHONE NO. /C} Cl .��` 0 0 f 9 SEPTIC TANK CAPACITY A �t�1r r SAC ``Ct/> tP�,/J6 C ado P r r LEACHING FACILITY: ��, 6 size k / S7a�J (type) ( ) NO.OF BEDROOMS BUILDER OR OWNER yc'6 f 1'9 Ili r`AJ PERMTTDATE: /T„=11 77 COMPLIANCE DATE:& L 2'z 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 fegt of leachin} f cility) Feet Furnished by ,l,- r�11.� `� �C� jZ7 ^ 00 O® 'op ac 7 No. 3CL15 THE COMMONWEALTH OF MASSACHUSETTS FEE BOAR - °OF +i EALT ,14x� OF c �eit_ Aldfk , ! APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct ( JXRcpair ( ) Upgrade ( ) Abandon ( ) - Complete System ❑Individual Components 6_20- 1l _ .A.. . (!CVv/,` l 1atii, Owner's Name Map/Parcel# Address Lot# Tcl/cphonc# Install tc Designer:Na& Address y Telephone# �00 18 Telephone# Type of Building: Lot Size 61 COO Sq.feet Dwelling—No.of Bedrooms Garbage Grinder ( ) Other—Type of Building No.of persons U2 Showers ( ), Cafeteria ( ) Other fixtures Design Flow(min. required) gpd Calculated design flow3�J gpd Design flow provided 35!Sgpd Plan: Date La-(2—cm Number of sheets _ Revision Date Description of Soil(s)(�'`— " u c!l_ U�= °t -i S ' " " ��+ ?G S I' " Sd- Soil Evaluator Form No. Name of Soil Eva Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS The unders' ned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and fu r agrees not to place the sys%ioperation until a Certificate of Compliance has been issued by the Boaarrdd of Health. Signed Date Inspectio FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 ,� No. �3'L/----' THE COMMONWEALTH OF MASSACHUSETTS' FEE BOAR . �QE..-H EALT x OFk-) APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT R $pplication for a Permit to Construct ( Repair ( ) Upgrade ( ) Abandon ( ) - En Complete System ❑Individual Components Owner's Name OVA + ' 1 M,tp/P arcel# Address .. Lot# C Tcl one# V r Installwr'e'Namc - Dcsig cr: at yam-tvlfj( , �F /� ^y^� 'Qd I` W rctis o reV� Ma Q „ f `r-� Address 1 . Telephone# 3 �..00 Telephone# Type of Building: Lot Size 61000 Sq.feet. `6welling—No.of Bedrooms Garbage Grinder ( ) Other—Type of Building No.of persons L 'Showers ( ), Cafeteria ( ) Other fixtures Design Flow(min. required) 7�-:>. gpd Calculated design flow3!� gpd Design flow provided 5!Sgpd Plan: Date L`12'c1 Number of sheets Revision Date _'Titl _1:1'(- Description ofSoil(s) tn -�� <iG1Mut �- Soil Evaluator Form No. Name of Soil Eva uatorlKo:4 SGtaticlu Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS ° f The unders'u,�ned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and fu r agrees not to place the system i operation until a Certificate of Compliance has been issued by the (BBo'aa`rdd of Health. Signed Date Inspectio FORM t - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 ,t No. 9 -7 THE COMMONWEALTH OF MASSACHUSETTS FEE BOARD OF HEALTH CERTIFICATE OF COMPLIANCE Description of Work: ❑ Individual Component(s) D. Wmplete System The undersigned hereby certify that the Sewage Disposal System;Constructed( ),Repaired( ),Upgraded( ),Abandoned( ) by: c 1Y1 c C 41G at -1r) � has been installed in accordance with the provisions of 310 C R 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. q`j -.xs?05 dated Ao %. Approved Design Flow (gpd) Installer Designer: r7 Inspector \ I�� '� Date The issuance of this certificate shall not be construed as a guarante`;hat the system will function as designed. FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96 r+ Na ( 7 �` �� THE . MMONWEALTH OF MASSACHUSETTS FEE /00 a�_,Av WSIMU"BOARD OF HEALTH DISPOSAL SYSTVRepair ONSTRUCTION PERMIT Permission is hereby granted to Co struct ( ) pgrade ( )) Abandon ( ) an individual sewage disposal system at � ( �P � � � � � - as described in the application for Disposal System Construction Permit No. 'l 7 o!S, -,dated,-,r- � Provided: Construction shall be completed within three years of the date of th' 11 local conditions must be met. Date 12 71tq-7 Board of Healt FORM 2 - DSCP DEP APPROVED FORM 5/96 FORM 1255 (REV 5/96) H&W HOBBSB WARRENTna PUBLISHERS- BOSTON NOT TO SCALE TOP FNDN. FINISH GRADE OVER FINISH CPA DE EL .- FINISH GRADE a; FINISH GRADE OVER D.�'•,�T. SOS OVER TRENCHES A la:0 SEPTIC TANK � -51' 12 MAX. TOTAL LENGTH OF TRENCH OUTLET PIPE LEVEL ' :a FOR 2 FT. MIN. 4 �./ °�°. a .3w 'w..•. ''"' :®;w _... •8f "' ':cJ• :w ",,' •o .v• btb:,®o 1� R A� aorta .° ®U� 40 b0 Er u -r^-,- q a' p a o o �3, G 4 �° ��a :.4•.m:a. oa o@ ,� its r C. I. OR PVC TEES a -='> -•- �.2,�a C ® a _ Po a 1500 GALLON � � � - --- - ----- _ ELM 7F �a.;.Q.° � 4,p INS TALL ON LEVEL BASE '°500 GALLON DP Y EL S ®A r{ o•Q q ®� ��,/g pry y/� g^®,��9 �Y/�q$p,.-���,p�� /r/p.-.� P/ !E / 4r�4.✓ 4,.�ii !9.� / 6... _H-• 0 PEINFOPCED TRENCH d. a- •d?ca.'o.X.d,:,°q'.bfjh': '�.,;G! •° 'A•;?':`� s•�" S7 p ®'�.p °., Q4;•�.. W ®:sa.•o,.v . •o•a•• •rr•o -~�::p..a..a. .'4y:'��.®;4t3, ;q•a. �.�: ON SEP TIC TANKS)EC INSTALL ON LEVEL BASE NO TE: E 'CA VA TE TO EL EV V. " �'`� OR h ..� L OP,,/ TO PL,..HOVE ALL IMPERVIOUSr- ._ MATERIAL RIFNEArH THE LEACHING AREA 12 N. /r � Dx',a�'. REPLACE EXCAVATED ,MATERIAL WrTee! _ �_�-- �� ..�" OF ?/G"--?/2'1 ,o • -j /y , ^ /•. Cam.EAN, CLAY FREE SAND , ��•a�: =.'m '.'•� ,4. YA SHED PEA STONE /® M B/ r '•' •p- q e_ �'A' �PED CRUSHED STDNE �' ' `'v 1, '�"a 7 I ....,,...__.,,..._,.........«...........1..,,.�.-,...,,:N..,. , . ... ..ra.�.,�.... .x,�.,.,,, .,,, ...• _,_,. „, -, „�,,m^�h' ter; ^�''' f.� ,'w,� " "✓ TRENCH HID TH / S° ASSUMED NUMBEP OF TPENCHE, I —, .�, ALL ELEVATIONS �aHO�"1N ARE D��,�ED ✓N A S / 2. ALL PIPES IN THE. S YST,SM MUST BE CAST IRON 1��Ur 1T3t P OF CAR YPIEL L S 2 G OR SCHEDULE 40 PVC. 3. THE BOARD OF HEAL 7 H MUST BE NOTIFIED , WHEN CONSTRUCTION 155 COMPLETE PRIOR PEPCOL A TION RA TE' TO BACKFILLING y !"$+I THE A ./f/n Gj I"rr s^/r..�. /-^. _.ram.,v .^,it-r �`/j/ 'G�'/i 4. ANY CHANGES IN THIS PLAN MUST BE APPROVED �`5 MIA.f.TN. .o • BY THE BOARD OF HEALTH AND CAPE i' ISLANDS S ;ED BY* SURVEYING CO.. INC. G. DUNNING E. MATERIALS AND INSTALLATION SHALE. OBE IN 4 /5 4 BARNS. B, D. OF HEAL TH � , COMPLIANCE I TH THE STA TE ,RANI TA;P Y T CODE _ TI Tip L V "- AND L OPAL APPLICABLE -- -- m - - - - _ RULES AND R, GUL A TIONS _ - - _ 7 G,'y NfJiFd C11�- 6 ED ?�.J€J9, G. NORTH AFPR® 1.5 FROM RE-CORD PLANS AND �, .� ',-=�-�---_�--.a�Y•-, ,��v r�, ���..- IS NOT TO BE USED FOR SOLAAl PURPOSES � GA,��A G� DISPOSAL N� � �.. , , .� , „ � .�3® GAL . �. FLOOD HAZARD ZONE C (NON-HA.�AFO1 DA,IL Y FL B. PdA TER SUPPLY TOWN W.TES? c, v ,'�, 1pT.� TANK F� 'D. 1500 GAL . rz"7 SEPTIC TANK PRG V1'DED 1500 GAL h L EA CHINS PE19UIPFD .�30 GPD. r� L �__7 13Z ` ; a SIDENALL AREA 1B2 S.F. 152 ®. 74 112 / p 1 5� c�y c� s- ca y, %r�3 __-___S.F.X___.__G,9 F. • GPD. BOTTOM AREA - . 2 • .F. LEGENDi mac, ,. __ ._w_ 32,9 S.F.X.O. 7�F. 24,3 GPD z M ``''"m s"" " L EA CHING PROVIDED 355 GP D 7 ---- - ` ---PROPOSED ELEVA TION y �` �`� -----74' -- EX STING CONTOURSINS L.E FA MIL Y / OBSERVA TION PIT 0 DISTRIBUTION BOA ?:t��bAr �A. I PREPAPED FOP �4 y s 3 9 0 , ►.,, e� SEPTIC TANK `` `' GEO GF A L.L.A IN h L• O T 132 (HSF. NO. . S) SIHFA FFEP PD. —.—! RESERVE AREA ��� CC TEP LLF -- N ` A LE -- MASS. PIPE INVE, T EL EVA TION rH�A � ���, /�. ,;: GA :' ,�,� CAPE I SLAAID S FNGIN�'ERINGPLOT PLAN•. � / J �-------- :\ to „ SCALE .S' NC TE 133 FA L MOU TH FPOA D - SUI TE 2E .SCALE 1 'ro 4 F, �•,v� " _ ,r ' r / - Gi / PLAN Nye'. r / NA,"HPLF, NA SS. MAP L C PL'L L 0T Ho . '"