HomeMy WebLinkAbout0343 SKUNKNET ROAD - Health 343 SKUNKNET ROAD, CENTERVILLE
A=170-113
i
TOWN OF BARN/STABLE
LOCATION 3 SEWAGE #
VILLAGE- Cr=a-% / ASSESSOR'S MAP & LOT 17d- 113
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type).g—' t,�-C 4,; Lei (size)A
NO.OF BEDROOMS 3
BUILDER OR OWNER ^�s
PERMITDATE: ^7°` $" COMPLIANCE DATE: 36- 4,?;'-
Separation Distance Between the:
W
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
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No. Fee 5 0 .0 0
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
1 Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE. MASSACHUSETTS
-- J , ZIpprication for Zigpogaf *pgtem Cougtruction Perron
Application for a Permit to Construct( )Repair(( x)Upgrade(( )Abandon(( ❑Complete System O Individual Components
� P ) P Y P
Location Address or Lot No. 343 Skunknet Rd Owner's Name,Address and Tel.No. 7 9 0—5 8 4 5
Assessor'sMap/Parcel Centerville Harvey Morris 343 Skunknet Rd
Centerville, MA
Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No.
W E Robinson Septic Service
PO Box 1089 , Centerville, MA
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder(no)
r 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 Type of S.A.S.
Description of Soil a a n cl
4,
r .
Nature of Repairs or Alterations(Answer when applicable) Tit 1 e 5 Leaching consisting of
D-Box and two 500-gallon precast leaching chambers.
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
to 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 issued by t B d of He th.
Signed !tI �
6 Date
rApplication Approved by Date 7 7— q
J' Application Disapproved for th follo ' g reasons
Permit No. — Date Issued
�d'� d ,• try a •.{ ".�""'�'��j_,,.,.+r'.'r� 6,.r,r'.�`..�.....p.,3.a,r..:•,.,,w.,«.P...«..,«.�.... ..�� � ...,..__.�,.�1*•^�......,-+. . .. -.-- .. .....+«...n.'�I
x
4 No. a Fee 5 0:O 0
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
.y, Yes
,PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS
application for Mioogal *raem Construction Permit
Application for a Permit to Construct( )Repair(x)Upgrade( )Abandon( ) ElComplete System El Individual Components
4 Location Address or Lot No. 343 Skunknet Rd Owner's Name,Address and Tel.No. 7 9 0—5 8 4 5
Assessor'sMap/Parcel Centerville Harvey Morris 343 Skunknet Rd
Centerville, MA
Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No.
W E Robinson Sdptic Service
PO Box 1089, Centerville, MA
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder(no)
Other Type of Building oysons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
v Plan Date Number of sheets Revision Date
` Title
Size of Septic Tank Type of S.A.S.
Description of Soil sand
Nature of Repairs or Alterations(Answer when ap licable) Title5 Leaching eonsiettng of
D-Box. and two 500-gallon precast leaching chambers.
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 issued b t ' B d of He th. Date �`� 4
Signed GV c�nJ
Application Approved by "`` �� In ,,,�.,.� Date
Application Disapproved for thYfollo4' g reasons
Permit No. Date Issued ^�
THE COMMONWEALTH�,OF MASSACHUSETTS
Morris ' 131tRNSTAB'L''E, MASSACHUSETTS
Certificate of (Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired (XX)Upgraded( )
Abandoned( )by
at 343 Skunknet Rd, Centerville has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. a-')dated
Installer W E Robinson Septic Sry Designer
The issuance of thi§7 '31�0 n jeFonstrued as a guarantee that the system will.function as designed.
Date Inspector
U
No. $' �- ��... ----------------Fee 50.00
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
Morris 'i5pogal *pgtem Con.5truction Permit
Permission is hereby granted to Construct( )Repair( X)Upgrade( )Abandon( )
System located at 343 Skunknet Rd
Centerville
Installer:Installer:LW E Robinson Septic Service
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: 77 - 7 1 Approved by_ 1
NOTICE: T is Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
CERTIFICATION OF SKETCH AND APPLICATION FOR A
DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT
ENGINEERED PLANS)
I, William E. Robin on, Sr ,hereby certify that the application for disposal works
construction permit signed by me dated , �'- �/ , concerning the
property located at 343 Skunknet Road, Centerville, meets all of the
following criteria:
* There are no wetlands within 100 feet of the proposed leaching facility.
* There are no private wells within 150 feet of the proposed septic system.
* There is no increase in flow and/or change in use proposed.
* There are no variances requested or needed.
* If the proposed leaching facility will be located with 250 feet of any wetlands,the bottom of the
proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted
groundwater table elevation.
Please complete the following:
A)Top of Ground Elevation(according to the Engineering Division G.I.S. map)
B)Observed Groundwater Table Evaluation(according to Health Division well map)
SIGNED: y DATE
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER 20_1998
(Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan,
this plan should be submitted).
1
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TOWN OF BARNSTABLE
LOCATION 3 `/.-,T r< SEWAGE # 7
VILLAGE. C.=�-i- ASSESSOR'S MAP & LOT 176- ,(i j
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY //-Cr
i
LEACHING FACILITY: (type),Z-A, c 4-,'7- Le, (size),;-- -o;2, '
i
NO. OF BEDROOMS .3
BUILDER OR OWNER 41`2-1 t w s'
PERMITDATE: 777-5�F 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
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
t
within 300 feet of leaching facility) Feet
f Furnished by
J
COMMONWEALTH OF MASSACHUSETTS
ID
EXECUTIVE OFFICE OF ENVIRONMENTALTAFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTEC*TI'ON
ONE WINTER STREET, BOSTON, MA 02108 617-292=5,500 `
YJ
WILLIAM F.WELD 113 P�G TRUDY CORE
Governor Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner
PART A
CERTIFICATION
Property Address: 343 Skunknet Rd, Centerville Address of Owner: Harvey Morris
Date of Inspection: 7—:3�` `� (If different)
Name of Inspector: WM E Robinson Sr
1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: dim E Robinson Septic Servi r,A
Mailing Address: PO Box 1 089, C ntervi 1 1 A , MA 02632
Telephone Numbers 5 0 8`•. 7 7 ci_R 7 7 6
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
_ Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: Date: �> /- R O
The System Inspector shall submit a copy of this inspection report to the Approving Authority 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.
INSPECTION SUMMARY: Check A, B, C, or D:
A] SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
COMMENTS:
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.
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 conforming septic tank
as approved by the Board of Health.
(revised 04/25/97) Page 1 of 10
DEP on the World Wide Web: http:/Avww.magnet.state.ma.us/dep
C'j Printed on Recycled Paper
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 343 Skunknet Rd, Centerville
Owner: Morris
Date of Inspection:
B) SYSTEM CONDITIONALLY PASSES (continued)
_ 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). Describe observations:
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
_ The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
qFURTER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
onditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
ublic health, safety and the environment.
YSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
HICH WILL PROTECT THE PUBLIC HEALTH AND 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.
r
2) SYSTEM WILL.FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to 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, 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 (approximation not valid).
3) OT7HER
(revised 04/25/97) Page 2 of 10
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 343 Skunknet Rd, Centerville
Owner: Morris
Date of Inspection:
D] SYSTEM FAILS:
You ust indicate ei;�;er "Yes" or "No" as to each of the following:
1 have determined that the system violates one or more of the following failure criteria as defined 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
he failure.
Yes No
q Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped _.
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality 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 mus indicate either "Yes" or "No" as 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
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area- IWPA) or a mapped Zone II of a
public water supply well)
The ow er or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
require ents of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 04/25/97) Page 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 343 Skunknet Rd, Centerville
Owner: Morris
Date of Inspection: 7-3/—y
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
Pumping information was provided by the owner, occupant, or Board of Health.
None of the system components have been pumped for at least two weeks and the system has been receiving normal
flow rates during that period. Large volumes of water have not been introduced into the system recently or
as part of this inspection.
_ As built plans have been obtained and examined. Note if they are not available with N/A.
_ The facility or dwelling was inspected for signs of sewage back-up.
_ The system does not receive non-sanitary or industrial waste flow.
LI/ _ The site was inspected for signs of breakout.
LI _ All system components, excluding the Soil Absorption System, 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 Soil Absorption System on the site has been determined based on:
The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal System.
_ Existing information. Ex. Plan at B.O.H.
Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) [15.302(3)(b))
(revised 04/25/97) page 4 of 10
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 343 Skunknet Rd,Centerville
Owner: Morris
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow: j/9S -p.d./bedroom for S.A.S.
Number of bedrooms:
Number of current residents:,
Garbage grinder (yes or no): �
Laundry connected to system (yes or no): �5
Seasonal use (yes or no):��0
Water meter readings, if available (last two (2) year usage (gpd): 1 9 9 6 — 73, 000g
Sump Pump (yes or no): 10 1997 - 81 , 000g
1st limos. 1998 - 32 , 000g
Last date of occupancy:
C MERCIAUINDUSTRIAL:
Type f establishment:
Des;
g flow: gallons/day
Grease trap present: (yes or no)_
Industr al Waste Holding Tank present: (yes or no)_
Non-sj nitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings, if available:
Last date of occupancy:
OTH R: (Describe)
Last f occupancy:
GENERAL INFORMATION
PUMPING RECORDS nd source of information:
f+'e 4
System umped as part of inspection: (yes or no)_
If yes, volume pumped: gallons
Reason for pumping:
TYPE OF STEM,
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. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information: ��, zEe,r i -7;36--
Sewage odors detected when arriving at the site: (yes or no) 4,-6
(revised 04/25/97) Page 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 343 Skunknet Rd,Centerville
Owner: Morris
Date of Inspection: I
BUILDING SEWER:
(Locate on site plan)
Depth below grade:
Material of constru � _✓cast iron _40 PVC_other (explain)
Distance from a� ater supply well or suction line
Diameter
Comments: (co)r ion of joints, venting, evidence of leakage, etc.)
IV
SEPTIC TANK: I/
_
(locate on bite plan)
1
Depth below grade-
Material of construction: concrete _metal _Fiberglass _Polyethylene _other(explain)
If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No)
Dimensions:
Sludge depth: 0 : ►
Distance from top of sludge to bottom of outlet tee or baffle:413
Scum thickness: 0 ,
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
How dimensions were determined: d 04 - — I-�"-
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.) lb �-O r',/ T� ��. J< ) ► tS lip- ✓UGC
.i a'• CAI 7>�ss w 3T� .Z�.rr.�'ivI S5
GREAS TRAP:
(locate o site plan)
Depth bel w grade:
Material o construction: _concrete _metal _Fiberglass _Polyethylene _other(explain)
Dimensio s:
Scum thi kness:
Distanc- from top of scum to top of outlet tee or baffle:
Distan a from bottom of scum to bottom of outlet tee or baffle:
Date f last pumping:
Comme ts:
(recomm ndation 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:)
(revised 04/25/97) Page 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 343 Skunknet Rd, Centerville
Owner: Morris
Date of Inspection: '7 7�
TIG T OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection)
(locate on site plan)
Depth low grade:
Material of construction: _,concrete _metal _Fiberglass _Polyethylene —other(explain)
Dimens ons:
Capaci gallons
Dei
flow: gallons/day
Alalevel: Alarm in working order_Yes; _ No
Daf previous pumping:
Coents:
(coion of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert: V
Comments:
(note if level and'distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
PUMP CH BER:_
(locate on sit plan)
Pumps in wor ing order: (Yes or No)
Alarms in wor ing order (Yes or No)
Comments:
(note conditio of pump chamber, condition of pumps and appurtenances, etc.)
(revised 04/25/97) Page 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 343 Skunknet Rd, Centerville
Owner: Morris
Date of Inspection: 3 947
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 be present, explain:
Type:
leaching pits, number:
leaching chambers, number:--
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, c9 (dition of vegetation, etc.)
FA C lei�f �L i�r�l. I�c 1Z7
CESSPOOLS: _
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet inv rt:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow (cesspool must be pumped as part of inspection)
Comm nits:
(note c dition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:
(locate n site plan)
Materials of construction: Dimensions:
Depth of solids:
Comme�ts:
(note cq dition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 04/25/97) Page 8 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 343 Skunknet Rd,Centerville
Owner: Morris
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate,where public water supplyhcomes into house)
a
r•
(revised 04/25/97) Page 9 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 343 Skunknet Rd, Centerville
Owner: Morris
Date of Inspection:
k
Depth to Groundwater Uzz- Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observation of Site (Abutting property, observation hole, basement sump etc.)
Determine it from local conditions
Check with local Board of health
Check FEMA Maps
Check pumping records
Check local excavators, installers
Use USGS Data
Describe inyour ow. words how you established the High Groundwater Elevation. Must be completed)
T s i 77
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(revised 04/25/97) Page 10 of 10
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Application is hereby made for a Permit to Construct (��or Repair an Individual Sewage Disposal
Location-Address
r Address
..r
4if's-ia?er**
Address
Type of Building Size Lot..... ...5-42.Sq. feet
Dwelling—No. of Bedrooms........ ..............--_----------Expansion Attic Garbage Grinder
Other fi
Other Distribution box Dosing tank
Percolation Test Results Performed by-Wfid.7— j��....
----------------------
1 e tui n ed agrees to install the aforedescribed Indi *dual Sewage Disposal System in accordance with
sl Uersigned further agrees not to place:/the s�st
ro si s of'LI71Z 5 of the State Sanitary Code— The ( 0�em
operatio , ntil a Certificate of Compliance has be ss 21, d of health.
d.... ..... .. ............................................ .....50.1.........
Date
-----'------
oat"
� Permit
Date
�
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...... . .............................OF........ /� \.)-S` -. .................
Appliration for Uhip ii al W orka oustrurttnn Famit
Application is hereby made for a Permit to Construct (\/) or Repair ( ) an Individual Sewage Disposal
System at:
h ;�,7=�i ....................................�-�_=II v N` � • ....................
Location-Address or Lot No.
1 �_ ...............................C. �LJ .......1.u...... t�?T....�: "?-......_ `I i\ r. 4 M n SS -
•--------- ! .... ........----•---
a a O er �;,r"" Address
/� g
.r�'+� -5�L--..---•-••-----•------- ---- =� f
;alkr Address
d Type of Building Size Lot..... �:.._5.5.:`Q...Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
pa, Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
a' Other fixtures _______________________________ __
W Design Flow..............�'� .tea....................gallons per person per day. Total daily flow-------------_332 ................gallons.
WSeptic Tank—Liquid capacity..! L Vgallons Length...`.... Width................ Diameter---------------- Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No.............I------- Diameter.....LI.......... Depth below inlet.... _.: f�... Total leaching area._z 4`2...sq. ft.
Z Other Distribution box ( ✓) Dosing tank ( )
Percolation Test Results Performed by.���. _r�-.� �.c_. _...$....! _`''_" .................. Date......C_.t=_J-�:•"
a �..
,.a Test Pit No. 1....�............mmutes 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........................
-•--------•-----------------•-------......-•----...----------•----•-------------......_.....
0 Description of Soil.......`' '` } / . t .:: r _:..-Z -I-- -`'-.&r�J�� L' �=-w k- ---i.................
V ....................................-.�... ......•�-'--�-c'�,_�,z:S _ 5 ............-r--.�-::..� 2........L.....................�_J7.....
W
x •----------•---------------------••-••••---•----•-----•--------••---••---•-•••-•--•••-••-•••----------••--------------._....----••••-•••---------•----•-•-•-•••--•-••••--•••----•-••••..................
U Nature of Repairs or Alterations—Answer when applicable................................................................................................
fA ierrt ,
.•��^^ T e un gned agrees to install the aforedescribed Indi idual Sewage Disposal System in accordance with
1he promo isi s of'ITL L 5 of the State Sanitary Code—The dersigned further agrees not to pythestemioperatio ntil a Certificate of Compliance has be ssu tl by e •o •rd of health. .•••---....•--
Application Approved BY //
•-�� •-- - .^---��"`y�- :".-�. ..--•---. .W—1
Date
Application Disapproved for the following reasons:..............................................................................................................
....................................................... ........................................_........................................................................ ...............................
Date
PermitNo--------------------------------------------------------- Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD`% F HEALTH
..........................................OF...... -..:.._ .:3.:.. : ..,t�'.. .. �Vne. .............
fit Wrr ifiratr fit TompliFanr
THIS IS TOE. CERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( )
b ------••.._...f..,. '�°` ------------------ ------ --------------------------------•---....---.........----------•-.
Y i - c. .. stalle I �^I
tP
at............. /--•-�-�--- •---- " T ` ----I---- - -------------- . ` - w•r
has been installed in accordance with the provisions of T! 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit NO. ........ `a.. dated .- ze one..-•---•--..
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CO S RUED AS A GUARANTEE THAT THE
SYSTEM WILL F NC ION SATISFACTORY.
DATE...............({}• .......................................... Inspector....
THE COMMONWEALTH OF MASSACHUSETTS
F H� B A R O EALT
a
�.
...... .". FEE --......
Biliplis al Tvnvtrnrfiv anti#
Permission ish eby granted /? ;Forkv
�- +�f - = - _ s1u`{ /�..........................
to Constr t or Repair ( ) at> Individual Sewag; Di s sal System
at No 6` U / ;l -- -
``. --------_----------•--
Street
as shown on the application for Disposal Works Construction Per it No �"_
DATE......... ................- •-. Board of Health
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS
qj
4 ILL ACE
I H S T A LLER'S H AA? E ` 11z ADDRESS
I U.UDE R OR OWNER
DA If E PERfAI T ISSUED 5Llb �
Ij ,ATE C 0 M F L I A N C E ° SSUtD
r
w
u�
3a'
,`�t
�y
i
SITE PLAN sHEEr I of 2
SCALE: I . 13,,'
j 100 �
10
f �-
I
r o (OIJv !w A.L.-
3 "0 0 .6 Ip r-T I L -rA .1J
N .0
s �
L N z7
FL"�1..58.n
N 13 IA
P3-7 A- '
fit.. 55.3 ILI ; f
0
6z, 5n
P 5c,r,t
T6
Alassq�
C
�. WILLIAM
v IIA. • "'
WARWICK
NO. 19771
�t.p�*4 l&O�+ o
L�eQ/LttJiG/C
REGISTERED LAND SURVEYOR FOR
ZONE ' G 5-- r'...)-Y'm km,y 1 ',..1..
PLAN REF. DATE
BENCH MARK DATUM FI � �-� `�'--��-`✓F Y WM. M. WARWICK 8 ASSOC., INC.
DOMESTIC WATER SOURCE -rZ::>VJQ w At 8OX '80I - NORTH FAL MOUTH
FLOOD ZONE.- 11J-2t-a- s,, Ate,C� a MASS..02556 - (617) 563 -2638
kL �.>
LEACHING BASIN SECTION NOT TO SCALE
24 C.I.MH COVER
EARTH FILL BRICK AND MORTAR COURSES AS REOD• TO...BRING
COVER TO GRADE
4 -14 B" FLOW LINE
INLET 2 TO WASHED PEA STONE FREE OF IRONS,
PIPE FINES AND DUST IN PLACE
��11 : '1"• OPENING WITH 4%B" 1 V4 TO l%2 WASHED CRUSHED STONE FREE OF
OUTER DIAMETER IRONS, FINES AND DUST /N PLACE
AND 1414„ INSIDE
DIAMETER % 1. CONCRETE TO BE 4000 PSI 28 DAYS
2. REINFORCED WITH 6%6° NO. 6 GA. W.W.M.
3. 2'AND 4' SECTIONS ARE AVAILABLE FOR
• GREATER DEPTH- REQUIREMENTS
M410"IN. 31� s o Zl I 3`�1 4. NUMBER OF PITS REQUIRED b
1 EFFECTIVE DIAMETER NOTE: EXCAVATE TO ELEVATION.: OR
(NOT TO EXCEED .1 TIMES EFFECTIVE DEPTH) LOWER AS REQUIRED TO REMOVE ALL
WATER TABLE LOAM AND CLAY BENEATH PIT. REPLACE
EXCAVATED MATERIAL WITH CLEAN
TYPICAL PROFILE GRAVEL TO DESIGNED GRADE.
y$•c, 18"STD LT. WGT. C.I.MH COVER
4'C./F/P£ 4"B/T.FIBER PIPE
T
OWEL L/NG _ FLOW LINE TIGHT ✓DIN OUTLET LEVEL
o TO FIRST ✓O/NT
/4 OO 1 I0 00 1
C./. TEE 51 'o 111 0o0100 1 1 1 1
STD. PRECAST CONC. yj$.07 I I ( 0 00 0 0 1 1 I I
od0 GAL.SEPTIC TANK 0/ST. BOX TO B£ 1 000 0 0 0 1 1 I
/NSTALLEO ON LEVEL, 1 11100 0 0 43
1 1 1
8 •_ STABLE BASE I 11 100 0 0 1 1 1 1
y�S£PT/C TANK TO BE 1 11 0 0 0 0 0 1 1 I I ;
INSTALLED ON LEVEL 1 11 1001 0 0 1 1 ' 1
STABLE BASE. 1 it 000 0 0 0 1 1 1
L 111000001111
EACHING BASIN '
1 1 1 p 0 0 0 1 1 1
BASE TO BE LEVEL 1 1110010 0 1 1 1 ,
SOIL AND PERC. DATA
PERC. RATE Z MIN. /IN. 011 TEST PIT NO. P 37(-4 011 TEST PIT NO. 2
Z' 7wo P�5 U ",ev,t J.
TEST BY : �?�� F-�1--�J 4 /s,,.�� �• �.Rav,�
WITNESSED. BY
TEST PIT GR. EL. 'E"5 I 71
—'I G LI A
�"A.IJ M fib, S �l
DATE: Ifl / z� / � 1�1
No wd .4:> 3 .
DESIGN DATA GENERAL NOTES
BEDROOMS 3 NO HEAVY EQUIPMENT TO RUN OVER SYSTEM.
DISPOSAL NotjV_:;� SEPTIC TANK, DIST. BOX AN LEACHING BASINS TO BE STANDARD
EST. TOTAL DAILY EFFL.2-'3oGPD PRECAST REINFORCED CONCRETE UNITS..
SEPTIC TANK loav GAL ALL SYSTEM COMPONENTS SHALL BE INSTALLED IN ACCORDANCE
SIDEWALL AREAL GAL./SQ.FT. TO REVISED TITLE 5 OF THE STATE ENVIRONMENTAL CODE,
MINIMUM REQUIREMENTS FOR THE SUBSURFACE DISPOSAL OF
BOTTOM AREA I• :: • GAL./SQ.FT. SANITARY SEWAGE EFFECTIVE ON JULY 1 , 1977.
LEACHING REQUIRED Zvr, SQ.FT. ANY CHANGES TO THIS PLAN MUST BE APPROVED BY THE BOARD
ACTUAL LEACHING AREA OF HEALTH.
�.S0.FT. AT COMPLETION OF CONSTRUCTION, PRIOR TO BACKFILLING, THE-
BOARD OF HEALTH SHALL BE NOTIFIED FOR INSPECTION.
PITCH ALL SEWER LINES 'A" / FT. UNLESS INDICATED 'OTHERWISE.
SEWAGE DISPOSAL SYSTEM
for MARTIN 9'
E.
chi MORAN vim, �a—� �`T� `� L�1J t�ILI'�(�T Lam•
>!<23417� �
tt Gli/14
SCALE AS INDICATED DATE-'S I L flS
WM. M. WARWICK 8 ASSOC., INC.
8OX 801 -NORTH FALMOUTH
` MASS. 02556 - (617) 565 -2638
PROFESS/ONAL EN6/NEER