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HomeMy WebLinkAbout0867 STRAWBERRY HILL ROAD - Health 867 Strawberry Hill Road Centerville P A 230 172 OD(folve NO. 1521/3 ORA 1�- f Date: 7—O TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAME OF BUSINESS: R BUSINESS LOCATION: MAILINGADDRESS: paG3 Mail To: TELEPHONE NUMBER: Board of Health �O� — 79� �-R5 G S Town of Barnstable CONTACT PERSON: ' P.O. Box 534 EMERGENCY CONTACT TELEPHONE NUMBER: Hyannis, MA 02601 TYPE OF BUSINESS: S Does your firm store any of the toxic or hazardous materials listed below, either for sale or for you own use? YES NO P' This form must be returned to the Board of Health regardless of a yes or no answer. Use the enclosed envelope for your convenience. If you answered YES above, please indicate if the materials are stored at a site other than your mailing address: ADDRESS: TELEPHONE: LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health has determined that the following products exhibit toxic or hazardous character- istics and must be registered regardless of volume. Please estimate the quantity beside the product that you store. NOTE: LIST IN TOTAL LIQUID VOLUME OR POUNDS. Quantity Quantity ✓1/O Antifreeze(for gasoline or coolant systems) ItIO Drain cleaners NEW USED //0 Cesspool cleaners ,410 Automatic transmission fluid &0 Disinfectants Engine and radiator flushes - 2 Road Salt (Halite) .y 0 Hydraulic fluid (including brake fluid) Refrigerants S - Motor oils &Q Pesticides NEW USED (insecticides, herbicides, rodenticides) Gasoline, Jet Fuel //0 Photochemicals (Fixers) Zjfpiesel fuel, kerosene, #2 heating oil NEW USED ,,V0 Other petroleum products: grease, Photochemicals (Developer) lubricants, gear oil NEW USED ,4/0 Degreasers for engines and metal Printing ink M Degreasers for driveways & garages Wood preservatives (creosote) &0 Battery acid (electrolyte) Swimming pool chlorine X10 Rustproofers Lye or caustic soda Car wash detergents Q/ Jewelry cleaners Car waxes and polishes AM Leather dyes Asphalt & roofing tar Fertilizers /O Paints, varnishes, stains, dyes PCB's �/(/O Lacquer thinners 110 Other chlorinated hydrocarbons, NEW USED (inc. carbon tetrachloride) Paint & varnish removers, deglossers Paint brush cleaners Any other products with "poison" labels (including chloroform, formaldehyde, 1/Q Floor& furniture strippers hydrochloric acid, other acids) Metal polishes /�/OLaundry soil & stain removers Other products not listed which you feel (including bleach) may be toxic or hazardous (please list): S Spot removers & cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS f TOWN OF B ST LE LLOCATON SEWAGE #. 'ILLAG E ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER C' PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facili �` Feet Furnished by '�\ QG � � �dQ a A �A 3s` A.13 y� 3a6 O !A 4 g6 �7 3 q0 COMMONWEALTH OF MA-SSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL, AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION EEER RECEIVED 003 STABLETITLE 5PT. OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE.SEWAGE DISPOSAL SYSTEM FORM PART A ///�, / CERTIFICATION Property Address: ib / )q,-11 led Owner's Name: 7-1 V" S o c es- Owner's Address: Date of Inspection: S o20 0� MAP Name of inspector. (please print) r7r� �, - PARCEL , 7 Company Name:j lf� / LOT li�lailing Address: D 4' ayrti Dd6 � Telephone Number, o — CERTIFICA TION 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 Sec . -15.340 of Title 5(310 CivIR 15.000). The system: V Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Eails Inspector's Signature: xL11,-1�0 - -- - Date: S..a v �3 The system inspector shall submit a copy of this inspection report to the Apprc ing Authority(Board of Health or DEP)within 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 DEP.The ori=, should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. /1�71, /C-, wee d1 ��.�,��, , Notes and Comments /�r�►s �1.,e Close �v Coen-/ -V L.��,c1, Rlfer ti//(pbPr / � ve ew J`-.i'a ce_ , Gi v+,-) /7 oa H c' ��' """This report only describes conditions at the time of inspection and under e conditions of use cJ t tht� f �� time.This inspection does not address how the system will perform in the future under the same o conditions of use. r different Page 2 of t I OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: a19 S�h Owner: , PJ p c Date of Inspection: do Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Syst Passes: I have not found any information which indicates that any of the failure criteria described in 310 CNIR 1�.303 or in 310 CUR 15.30�t exist. Any failure criteria not evaluated are indicated below. Comments: B.�JSrjstem Conditionally Passes: /v One or more system components as described in the" repaired The system,upon completion of the replacement or Pass"section need to be replaced or P repair,as a rov pp ed•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 The septic tank is meta!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«ill 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: 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. Svstem will pas in approval of Board of Health): p spection if(with broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstru «iIl pass inspection if(with approval of the Board of Health): cted pipe(s).The system broken pipe(s)are replaced obstruction is removed ND explain: rjbc j vi L i OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A /�7 CERTIFICATION(continued) Property Address: t� / /f� f Owner- Date of Inspection: 3 261her 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- S,vstem will pass unless Board of Health determines in accordance with 310 CNIR 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 s`•stem has a septic tank and SAS and the SAS is-within a Zone 1 of a public water supply. _ The s}stem 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 "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: a rage+of t r OFFICIAL INSPECTION FORD[— NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address ACC / i �J Owner: 6�Z Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no" to each of the following for all inspections: Yes X — ✓✓�ckup of sewage into facility or system component due to 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 /7Clogged SAS or cesspool �Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or esspool v_.,liquid depth in cesspool is less than 6"below invert or available volume is less than%:day flow �/ Required pumping more than 4 times in the last year NOT due to clogged or obstructed r of times pumped P1Pe(s)•Number — Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface Otter supply or tributary to a surface water supply. if_,,-Any potion of a cesspool or privy is within a Zone 1 of a public well. y portion of a cesspool or privy is within 50 feet of a private water supply well. _ -A,,- Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from supply well with no acceptable water m a private water p quality analysis. (This system passes if the well water analysis, P=rformc•° DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates [:.,. :ne 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 arc triggered.A copy of the analysis must be attached to this form.] "�(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 lance system the system must serve a facility with a design flow of 10,004)gpd to 15,0oo 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 _ — the system is within 400 feet of a surface drinldng 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 trapped 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 la_r;e 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 CNfR 15.304.The system owner should contact the appropriate regional olbce of the Department. Page S of t l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B ,[ CHECKLIST Property Address: �� Owner: Date of Inspection: p Check if the following have been done. You must indicate`des"or"no"as to each of the following: Yes o Pumping information was provided by the owner, occupant, or Board of Health Were anv of the system components pumped out in the previous two weeks Has the system received normal flows in the previous two we ek eek period '1/ Have large volumes of water been introduced to the system recently or as part of this inspection Z - P� Were as built plans of the system obtained and examined?(If they-were not available note as N/A) t Was the facility or dwelling inspected for signs of sewage back up Was the site inspected for signs of break out Were all system components,excluding the SAS, located on site _ Were the septic tank manholes uncovered opened,and the interior of the tank inspected for the condition oft es or tees, material of construction,dimensions,depth of liquid,depth of sludge and depth of scum _ 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: VYe no Existing information. For example,a plan at the Board of Health Determined in the field(if any of the failure criteria related to Part Cis at issue approximation of distance is unacceptable) [310 CNIR 15.302(3)(b)l Page 6 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSES E SMNTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address- /� �' ✓, /� Owner. Date of Inspection: 0 RESIDENTLkL OW CONDITIONS Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CNIR 15.203 (for example: 110 gpd x#of bedrooms): ���Number of current residents: �— Does residence have a garbage grinder.(yes or no): It"O Is laundry on a separate sewage system(yes or no):�9(if yes separate inspection rcquiredl Laundry system inspected(yes or no),4W Seasonal use: (yes or no): /f/0 Water meter readings,if available(last 2 years usage(gpd)): Sump Pump(Yes or no):/W Last date of occupancy: ._ CONMIERCIAL NDUSTRUL, Type of establishment: Design flow(based on 310 CAR 15.203): gpd Basis of design flow(sests/persons/sgf,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings,if available: Last date of occupancy/use: O'TUR :, bc): GENERAL P1FORINUTION Pumping Records � Source of information: Ite rr✓ � © � �l Pa✓j pumped as part of the' Was system um � If es volumepumped:--gallons (yes or no): Y —How was quantity Pumped determined? Reason for pumping: TTYP F'SYSTEMptic tank,distribution box, soil absorption system _Single cesspool — Overflow cesspool Pn�y _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): Approx:inate age of all components,date installed(if�,Peurcd soe of inf rmadon: � Were sewage odors detected when arriving at the site(yes or no): '(� Page 7 of 1 l OFFICIAL IIYSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS : SUBSURFACE SEWAGE DISPOSAL SYSTEM, 1 INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: VC P �- Owner: 1 �o ,�r✓� e' Date of Inspection: ao p BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction:_cast iron _4` 0 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: v(loate on site plan) /. Depth below grade: el Material of construction:�crete_metal_fiberglass 1 •eth_po lene _other(explain) —Polyethylene If tank is metal list age:_ Is age confirmed by a Ce�cate of Com Hance es or no :certificate) p (Y ) _(attach a copy of Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: 3/ Scum thickness: Y 1 Distance from top of scum to top of outlet tee or baffle: G Distance from bottom of scum to bottom of outlet tee or baffle: I/l How were dimensions determined: Comments(on pumping lated to outlet de recommendations,inlet and outlet tee or baffle condition a , structural integrity, liquid levels as Inv rt,evince GREASE TRAP:�/l(locate on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass_polyethylene other (explain): _ Dimensions: Scum thicknness: Distance from top of saun to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee orb ffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle conditio as related to outlet invert,evidence of leakage,etc.): structural integrity, liquid Ievels Page 8ofII OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner. Date of Inspection: Q TIGHT or HOLD LNG TANK: must be pumped at time of inspection)(locntc on site plan) Depth below grade: Material of construction: concrete metal—fiberglass_polyethylene other(explain): Dimensions: Capacity:_ �tLlons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping Comments(condition of alarm and float switches,etc.): DISTRIB G t 1% LO`C;_L/(tL present must be n n pe ed)(locate on site plan) Depth of liquid level abo,-: .. invert: 4CV'-1"d Comments(note if box is lc•.clacd distribution to outlets equal,any evidence of solids carryover,any evidence of leakagZto or out o�box,a c.): a /gyp> PGA t At 60�,�. . lli� �a 4- PUMP CHAMER:/-L"(locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtcnanccs.etc.): Page 9 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C / SYSTEM INFOMIATION(continued) Property Address: b • Pam., Owner: �e c Date of Inspection: SOIL ABSORPTION SYSTEM(SAS); (locate on site plan,excavation not required) If SAS not located e.,cplain why: TO 1� eachtn its num / / Lv' g c ber.b CJ {o leaching chambers, number leaching galleries,number: leaching trenches,number,length: leaching fields,number, dimensions: overflow cesspool, number system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ndin etc.): Po g,damp soil,condition of vegetation, Ile C-4 CESSPOOLS: cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depot of solids layer: Depth of satin layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure, level of po dr n 'ag.condition of vegetation.etc.): PRIVY:AL(locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): Page 10 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM IISFORNIATION(continued) Property Address: (T tom/ Jn'o►� � �j(�� � Owner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two per ancnt reference landmarks or beni hmarks.Locate all wells within 100 feet. Locate where public water supply enters the building. L4 �- ce. ,4r 36 A)_ -41 j- Lot- IDIL_ ��� i� ' Page l l of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C / SYSTEM INFORMATION(continued) Property Address: v� e Owner. " 00 Date of Inspection: do SITE EXAM 5 tope Surface water Check cellar Shallow wells Estimated depth to ground water o2 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained,from system design plans on record-If checked,date of design plan reviewed: served site(abutting property/observation hole} •thin I- feet of SAS) Checked with local Board of Health-explain: Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain; You must des be ii w you established the high ground wat er el anon: rvy D� � f �� •B/OG✓ 7-1 0 C') ODoo 00 ° 0 0(J 60 52 l�,� ►M�wa$ �o✓te c COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION A p W a N A d h a i� vev� TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 867 STRAWBERRY HILL RD CENTERVILLE,MA 02632 L1 Owner's Name: TIM DESROCHER Owner's Address: 867 STRAWBERRY HILL RD CENTERVILLE,MA 02632 Date of Inspection: 4/16/01 Name of Inspector: (please print) JOHN GRACI RECEIVED Company Name: SEPTIC INSPECTIONS Mailing Address: P.O. BOX 2119 TEATICKET,MA.02536 APR 2 6 2001 Telephone Number: 508-564-6813 FAX 508-564-7270 TOWN OF BARNSI-AcrL-E CERTIFICATION STATEMENT HEALTH DEPT. 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 _ ConditionalIN Passes _ Needs F r Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: 4/16/01 The system inspector shall sub it a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 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 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 THE SYSTEM PASSES TITLE V INPECTION. RECOMMEND PUMPING SYSTEM EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL 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'; IncnPrtinn Fnrm 611 5/?nOn 1 I Page 2 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) ` Property Address: 867 STRAWBERRY HILL RD CENTERVILLE,MA 02632 L1 Owner: TIM DESROCHER Date of Inspection: 4/16/01 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: THE SYSTEM PASSES TITLE V INPECTION. RECOMMEND PUMPING SYSTEM EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL 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 I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 867 STRAWBERRY HILL RD CENTERVILLE,MA 02632 LI Owner: TIM DESROCHER Date of Inspection: 4/16/01 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 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) V Property Address: 867 STRAWB ERRY HILL RD CENTER ILLE MA 02632 L 1 Owner: TIM DESROCHER Date of Inspection: 4/16/01 p I D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for alLinspections: 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 'I/ 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 nLa. 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.[ F _ _ (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 11 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. d Page 5 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 867 STRAWBERRY HILL RD CENTERVILLE,MA 02632 LI Owner: TIM DESROCHER Date of Inspection: 4/16/01 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)] 5 Page 6 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 867 STRAWBERRY HILL RD CENTERVILLE,MA 02632 LI Owner: TIM DESROCHER Date of Inspection: 4/16/01 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: 1 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)): n/a Sump pump(yes or no): NO Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sgft,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: n/a 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: 1986 Were sewage odors detected when arriving at the site(yes or no): NO h Page 7 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 867 STRAWBERRY HILL RD CENTERVILLE,MA 02632 L1 Owner: TIM DESROCHER Date of Inspection: 4/16/01 BUILDING SEWER(locate on site plan) Depth below grade:30" 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: 24" 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: 1000G L 8' 6" H 5' 7" W 4' 10"" Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 32" 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 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.): THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND. RECOMMEND PUMPING THE SYSTEM EVERY TWO YEARS. 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 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 867 STRAWBERRY HILL RD CENTERVILLE,MA 02632 L1 Owner: TIM DESROCHER Date of Inspection: 4/16/01 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.): 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 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: 867 STRAWBERRY HILL RD CENTERVILLE,MA 02632 L1 Owner: TIM DESROCHER Date of Inspection: 4/16/01 SOIL ABSORPTION SYSTEM (SAS): X (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 n/a leaching chambers, number: n/a n/a leaching galleries, number: nla n/a leaching trenches, number, length: n/a n/a leaching fields, number: nla 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 PIT IS STRUCTURALLY SOUND AND APPEARS TO BE FUNCTIONING PROPERLY.THE PIT HAD 2' OF WATER IN IT AT THE TIME OF THE INSPECTION. 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 Page 10 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 867 STRAWBERRY HILL RD CENTERVILLE,MA 02632 L1 Owner: TIM DESROCHER Date of Inspection: 4/16/01 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. B AB V3 4 AC, 3a ec EA in Page I I of 1 I a OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 867 STRAWBERRY HILL RD CENTERVILLE, MA 02632 LI Owner: TIM DESROCHER Date of Inspection: 4/16/01 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 12+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 NO 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) YES Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: USGS MAPS AND CHARTS- 12+FEET tt is Fil 61z-:- THE COMMONWEALTH OF MASSACHUSETTS ..�.---•� .._ BOAR® E H E A T H ./M�bl..............0F... ..5 .--e---r ..----..............----- ApplirFatilaat for Dh5pos al Works Tonotrurtivit Vantit Application is hereby made for.a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System t canon-AAdddress r Lot C. �.�y� p ner Address a ..........-Lyc••"i"/.:..t.J�..3...�../-. �C..43-L.J.J.--�-•---•---•--------•. ..................... -"x•-.•a-- --•-----•-----•--------------•---•-------••---••---- Installer Address d Type of Building Size Lot____b...._% - .Sq. feet aDwelling—No. of Bedrooms........... -----------------------------Expansion Attic (/V Garage Grinder (7& p, Other—Type of Building ............................ No. of persons_-_--___--__-__-_._..______- Showers ( ) — Cafeteria ( ) a Other fixtures W Design Flow................�ti�.................gallons-per person per day. Total daily flow..........._.:.........................gallons. 1:4 Septic Tank—Liquid'capacity Q_ VZ).gallons Length................ Width................ Diameter._._-___-__..._- Depth................ W Disposal Trench—No. .................... Width.................... Total Length.................... Total.leaching area....................sq. ft. x Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) . Dosing tank ( ) Percolation Test Results Performed bY.......................................................................... Date......................................... 14 Test Pit No.,��,QS._S_.....minutes per inch Depth of Test Pit..____. �..._�//Depth to ground water....... .......... . 1�rq-4 Test Pit N0. p�t/l I..minutes per inch Depth of Test Pit.. e `/depth to ground water" Description of Soil..... -------- --------------------------- ^ ......--- U ....................,..®....••• .�-----............. ......................................... 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 TITLE . 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. _ igne... 2 ------------------- .......... 000 aAPPlication Approved BY ............ ... . ... Date Application Disapproved for the f l owing reasons:--':...................:--------------------^---------------------------------------------....... ----- ........•-•-•••••......••••---•••....--•--••••••-•-••-•-••-_•••-•••••--••--•--•••--•--•......-•--•-•-•--..__....._...-•-••-•--•••-••-••-•--••••-••-••--•-••••••••• ..................................... Date dPermit No.....�L!. 4?-------------------------- Issued....................................................... Date 4 .............................. THE COMMONWEALTH OF MASSACHUSETTS ......BOARYF HEA' _ ...............OF. e. / ..........------------AjipfiratW4.fur Disposal Murky Timstrurtion ramit Application is hereb y, r a Permit to Construct or Repair an Individual Sewage Disposal -System at:/ .........../..... ........ ......... 4.4........ ...... c ti Address _oel S .1 o;.0 4 ..............I....7.7-<. ........ --------- ----- ...... Address 02/1.................... ..................... -f..................................................... D? ... .. Installer Address Type of Building Size Loec_��__ ---V__V.Sq. feet U Dwelling—No. of Bedrooms......... Garbage Grinder �?CX ............................Expansion Expansion Attic (.117q --j PLI Other—Type of Building ............................ No. of persons........................... Showers Cafeteria 124 Other fixtures ..................................................................................................... Flow................47;;�o .. . Design Fl ..............._........gallons per person per Total ow........11 day. Tl daily fl �3..�76 W . .................................gallons. 1:4 Y./,--Septic Tank—Liquid*capacity 6_0.0.gallons Length................ Width..._._.._._..... Diameter________-___---- Depth................ W Disposal Trench—No..................... Width.................... Total Length....._...._......__. Total leaching area....................sq. f t. Seepage Pit No--------------------- Diameter.............__..._. Depth below inlet........_........... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by......................................................................... Date--------------...------------........__. �--4 Test Pit NO. 1'..... ...minutes Depth of Test Pit Depth to ground water P,,,,. "u ........................ 44 Test Pit No. 4 --minutes per inch Depth of Test Pit.. /-P-Depth to ground water';;�V GG ...............? .......... - ------------------"-------------------------­"-------- 0 Description of Soil---.. ]Z..;r. 4�..... ...........: ­ .. ----------------**-------------------------- C ...... -le.2�.I _e73 ......................................................................................................................I....................................... 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 TITS 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health Sign ...................... Application Approved By e at ............ ...V j -------------......----------------------------­-------- --------- Application Disapproved for the Bowing reasons:................................................................................................................ ......................................................................................................... ........................................................................................ Date No----- - ........................ Issued....................................................... Permit 31�------- ---- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTM ............ OF...... ......................... (9rdifiratr of Toutphattrit THU-IS TO CE-R.TIFY, That,1he Individual Sewage Disposal System constructed ( 41"oor-Repaired by......: .......V 1------- - ........................................................... ...... ......... .................................. i e- . .....I--------- 160�L '. &Iler �� 14 V.4 's 4C .I .. . J ....5'_en_tee.at.- ...... ..........I...........�4. .. ...... ............ has been installed in accordance with the provi/lons of TITLE 5 of The State Sanitary Code as described in the QS- 4-79- application for Disposal Works Construction Permit No...... ................................ dated- - .................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE C NSTRUED AS A ARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. & DATE................. ....................................... Inspector-- . ........ ............................................................ THE COMMONWEALTH OF MASSACHUSETTS ,INSTRUE. ARA...... ....... BOARD OF HEALTH q5 .....4. .............................. ...............................OF..... No......................... FEE........................ Dispogat Works'Tonstruttion "pamit '17 Permission is hereby granted---- .5..... ............................................................................. to Con t ct r Repa• an S Di sal !�ystem In e I§PQ allo. -c VAUX...... A------------------------------------------------------- t . .........C(SIdA.e........ Z/ ......... Str-eet..... '7 as shown on the application for Disposal Works Construction Permit N .................... Dated.......................................... ........ ..... .. ---------- ----- . ....................................................... Board of Health DATE-------------------Co. 2S........................................... FORM 1255 A. M. su KI INC BOSTON �1 'J gfJ / Jr V1 Pt .. •::� ' `3 ~ �� 7` � Jam/ V V 'r � s'k• � .K\ aAlj. r•r� /O�C�9r'.la c�ALBERT MOftSE 40 00 W(9�So® sr OF A R DERT /V 7 ELDREDGE ` Z�j y No. 993:7 �Q GE1D XISTIN0 SPOT ELEVATION OzO CERTIFIED PLOT PLAN -EMOTING CONTOUR --- 0 --- FINISHED- SPOT ELEVATION [� `1141SNED CONTOUR 0 Wr :.`The location of any existing underground sewerage, •. wells, or other utilities shown on this plan is approx IN . imate only as determined from records and/or verbal �, A J1 h S TA.0� A . information. The contractor is responsible for the '�•l p�c�k/( :v S 7 ,� verification of the existing locations in the field. SCALES / _ 4. 0 DATE 0 .DREDGE ENENE'ER/NG CO. ING� CLIENT._________ I CERTIFY THAT THE PROPOSED EGISTERE =SRVEYOR STERED JOB NO. e3 0 ,71 BUILDING SHOWN ON THIS PLAN CIVIL LAND CONFORMS TO THE ZONING LAWS DR �.,�. ,-a-�. ENOINFLER OF BARNSTABLE , MASS , 712 MAIN STREET ' CH. BYE HYANN I S, MA$S. SHEET. / OF Z EYOR — DATE REG. LAND SURY 4 NOTE /F E/Tf{/ER::Ti�lE SEPT/G TAN!�C D/Q � ' �O �T MeN LACti. ArG.P/T 4R . :!`�ORL� >TN.9/V /2"®►Ed.OIN APIAAl F.TE-e CO/VCRjE•7-F.coNER v Sll�11411 gE ,8RDl16HT TG 4l�.Ar> .�.4/v ExTRA , ' GONC�@ETE A? RVC 'P/PE yEA Y C/�,y ST IRO R N GoiiL` / Sf/AL L !3E USEO A11N- P/TCN lFlN OR/✓Eyt/AY eL ,S3,cD COVERS lg'PER FT 2 CD/VCRE•TE •�r j ORADE Cd YER CZ FAN .SAN O . A i— 6AG,+CF/LL - - - _: -::. . _ Ll�t!/O L EYEL ..- �•' -' ' -2'LAYER `c9 0 0 G/1 L, v -� • • • • • • • • • a �• WA SHF0 STGNE i tW IN.P/TCN D/ST. o . . s • • • • O . . , % pB/t /T. SEPTIC TA NIX t; • s • s DEPTN • • o • •o WASXED .STONE p► a.. • • • • • • •+ • ••rPREC45T SEEA Q'Fy P/TOR EQU/V 490 6 - � IKveXT 4e'LEVA7'14vS 2- p.+c-J T y A GE /NYEAT AT EUILD/NG G,o FT ` 3 /Z 4F7. O/Afrl. C(-We.7,1W/L AT)ON, ' /lVLET .�PT/C' TANK 4•�FT, - a, 01174E7- SEPTIC TANN 49.6 FT /IVLFT OISTR/8l?!ON BOX `/ F7 SECT/OJV 4F GROVNO INTER TALE OtlTLETO/STR/B(!T/ON BQX 431.z-F7. SE;VA40E O/SPOSA L SYSTEM INLET LfACHIMCO /C"/T -49.0 fT '7"/48(�LAT/ON LF-ACHI V6 J'/T ol/yENSION A FT. DES/6N CRlTER/A JCALE : �4 I O' DI/4IENS/aN 8 4*#" JCT• NUMBER OF BEDROGMS GARartGED/SOO.SAL-UN/T SOIL LOG SOIL TEST TaTAG &JMMXr'EG FL.ONS/ .3.3 y G.4L.1DA�' SO/L TEST 02- SOIL TEST�,� kUMaER 0►F I,F,4GV/NZ PITS ELEY. 52.7 ELEY. �'� OA7-e OF SOIL TEST 4 S/DELEACH/NG PER PIT LSY SQ, -'7 r/ b 2- RESULTS IVIT/VESSED dY DOT'TOM LEa4Cl//NG PSR PIT e .; v Svr`sv !� PER COLA WOW JeA7Ar#/ LgSS ! jAVIJVCH TOTilL l EACH/NG AREA 6 `r SQ, f T. PERCOI-A'rlON RATE lk 2 T'4� M/N.//NGN RESERYELL=AC'NlN6 f4RE^ ?b4- SQ. FT MEL J'r nJL T Tf'' -�_, plc 7 _ OWL P REDGE ENG/N6rR1/,%CQ/ - r civic l7 Z �l�✓, 38:7 7!2 MAiN -9 -, NyANNI9, MA S. ND GRO ND WATER OWCOUNTEREO 3 1. 3MEt`T?-aF f� �; .--•�,-n �, - � ���'�''�' Q GItOUNO ySr'ATER AT ELE•j! JOB JVO_ � o `_ �, C LOCA �."Olul-* ] � SEWAGE PERMIT NO. cil VILLAGE 4�1kl1 I N S T A LLER'S . NAME I ADDRESS BUILDER OR OWN ER.,. ��vx19t -cr DATE PERMIT ISSUED (p/ �Z � •S-- DATE COMPLIANCE ISSUED _ _ - . - � 3 - r �� � 1 �� 6 .� }