HomeMy WebLinkAbout0083 WHIDAH WAY - Health 83 Whidah Way
F
Centerville P
A = 230 202
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ll7/lriPli(�® �� rz�
UPC 12534
No.2-153LOR
HASTINGS, MN
0
i
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIF:ONMENTAL AFFAIRS .
DEPARTMENT OF ENVIRONMENTAL PROTECTION_
/ g 8 '�'
11'Z005
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T OVvil J,- dAK:Va`fABLE
HF_ALTH DEPT.
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION -P 2 3p
/ ARCEL
Property.Address: `C�I�( Ce( r " --w---- ._-
Lai
to
Owner's Name:
Owner's Add'res :;_'U
Iry A-1 A 0D/lam
Date of Inspection: ,-
Name of Inspecto please rent / rt Lth�JY)`i
�,
Company Nam lee-
Mailing Address: `90 C�
Telephone Number: . "7 -G
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at tNs 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:
/Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
ils
Inspecto,`,`~'s Signature: r Date. i�C
The system inspector shall submit 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 repor_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
N
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
f
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: aa ak
1
Owner.
Date of lifspection a _,Y 6e
Inspection.Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. yytem Passes:
I have not found any information which indicates that any of the failure criteria described in3 10 CMR
15.303 Orin 310 CMR 15.304 exist.Ary.failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:.
One or more system component3 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,
The septic tank is metal and oveE 20 years old* or the septic tank.(wheiher 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..complyr--g 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 y.ars 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 pip.e(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
ob37uction is removed
distribution box is.leveled or replaced
ND explain:
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:
2
Page 3 of 1'1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CER/T�IFICATION(continued)
Property Address: ��_(.f�(�,(�=_
Owner 7 ✓ IJ�CC �
Date of spection: 67
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 E 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
"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 cr 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:
3
Page 4 of I I
OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS '
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 7
IJLtA
Owner"..'
wner r , v
Date of I spection ?` CPOC6—
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes N9
a/ Backup of sewage into facility or system component due to overloaded.or clogged:SAS or.cesspool '
Discharge or ponding of efflurnt to the surface of the ground or surface waters due to ah.overloaded or
clogged SAS or cesspool
Static liquid level in the distrbution.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 '/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 SAS, cesspool or privy is below high groundwater elevation.
_ Any portion of 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 of 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. [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 fret 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.]
PO (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
the.system is within 400 feet of 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
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 shall upgrade the.system.in accordance with 310 CMR
15.304.The system owner should contact the appropriate regional office of the Department.
4
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
Owner 0 n - —
Date of nspecfion: L
cl—
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes �o
Pumping.informat ion..was provided by the owner,occupant,or Board of Health
C//Were.any of the system components pumped out in the previous two weeks ?
_ V Has the system received normal flows in the previous two week period ?
/_Have large.volumes of water been introduced to the system recently or as part of this inspection?
t/ 'Were as built-plans of the system obtained and examined?(If they were not available note as N/A)
Was the facility or dwelling inspected for signs of sewage backup?
✓ _ Was the site inspected for signs of breakout?
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
of the baffles 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)or:he site has'been determined based on:
Ye 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 C is at issue approximation of distance
is unacceptable) [310 CMR 15.302(3)(b)]
5
Page 6 of I 1
OFFICIAL I.NSPECTION-FORM-,NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE"DISPOSAL SYSTEM INSPECTION FORM
PART C _
SYSTEM INFORMATION
Property Address. , �Jhy
A a f.
Owner �.
Date ofj
pection
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): . Number of bedrooms(actual):
DESIGN flow based on 31 O.CMR 15.=03 (for example: 11:0 gpd x#of bedrooms): "
Number of current residents:
Does residence have.a garbage grinder(yes or no): .
Is laundry on a separate sewage syste�mm2.(��'es or no)-_( if yes separate inspection required]
Laundry system inspecte (y•s or noh{/U
Seasonal use: (yes or no):aelp
Water meter readings if a PaEable last 2 ears usage o '��� �� /0l! OV/�
( X � (�Pd))�� � OJ �
Sump pump.(yes,or no)-
Last date of occupancy: ` &6C67ta�L
COMMERCIAL/INDUSTRIAL//"
Type of establishment:;
Design flow(based on 310 CMR.15.203): gpd "
Basis of design flow(seats✓persons/sdit,etc.):
Grease trap present(yes or no):_
Industrial waste holding tank present ayes or no):
Non-sanitary waste discharged to the Title 5 system (yes or no):_
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records X�/ -
Source of inforinadon: °
Was system pumped as part.of the inspect (yes or no
If yes, volume pumped: gallons--How was quantity pumped determined?: R
Reason for pumping:
7TYP OF SYSTEM
eptic 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_he DEP,approval
Other(describe):
Appr ximate age of all components, date 'nstalled(if known)and source of in ormation:
�. / >
Were sewage odors.,detected when arr ving.at the site(yes or no);
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:
1�
Owner:
Date of spection:; c=
BUILDING SEWER-(locate on site plan)
Depth below grade:
Materials of construction:_cast iron . 40 PVC_other(explain):-
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage, etc.):
SEPTIC TANK: locate on site plan)
Depth below grade:
Material of construction:—concrete_metal_fiberglass__polyethylene
—other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions:
Sludge depth: Q" / >�
Distance from top of sludge to bottom of outlet tee or baffle: JTd�
Scum thickness:Q.
Distance from top of scum to top of outlet tee or baffle:
Distance from bottomof scum to botto of outlet tee or baffle:
How were dimensions determinecf
Comments(on pumping recomm dation , inlet and outlet tee or baffle condition, structural integrity, liquid levels
*srelatecd,to outlet invert,evidence of leakage, etc. : ,
GREASE TRAP' locate on-site,plan)
.Depth below grade:_
Material of construction:_concrete_metal_fiberglass_polyetl:ylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle ccndition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage,etc.):
7
Page 8 of 11
OFFICIAL-INSPECTION FORM—,.NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM.INFORMATION(continued)
Property Address:��3 1jj6,&LA
A4 Owner:�(}..�A� ����o _,T)*i�
Date of Inspection: Us�—
I
TIGHT or HOLDING TANK:W(ank must be pumped at time of inspection)(locate on,site plan)
Depth below grade:
Material of construction: concrete metal fiberglass polyethylene other(explain):
Dimensions:.
Capacity: gallor_s. .
Design Flow: gallons/day
Alarm present(yes or no): -
Alarm level: Alarm in working,order(yes or no):
Date of lastpumping:
Comments(condition of alarm and float switches, etc.):
I
DISTRIBUTION BOX:Zofese-a must be o ened locate on site 'Ian P )( P . )
Depth of liquid level,above outlet inverse&
Comments (note if box is level and distri-:)ution.too os equal, any evidence of solids carryover,any evidence of,
4eaka2e into or out of box etc.):
PUMP CHAMBFOO (locate on s to 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 appurtenances,.ete.):
8
Page 9 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEhl INSPECTION FORM
PART C
SYSTEM INFORMATION(cdcrntinued)
Property Address: �t (
Owner ) a
Date of specfion
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
T Type
i
aching pits,number: 1
leaching chambers,number:
leaching galleries, number:
leaching trenches, number, length:
leaching fields,number,dimensions:
overflow cesspool, number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of pording, damp soil; condition of vegetation,
)• , , f l/
CESSPOOLS(cesspool must be pumped as part of inspection)(]ccate on.site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum 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 ponding, condition of vegetation,etc:):
PRIVY/1 L� (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.):
9
Page 10 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY.ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM.
PART C
SYSTEM INFORMATION(continued)
Property Address:.
Owner: � ���, �t ,
Date.of spection:
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.
bit
X/1�
�3
Pit
10
PaLye I I of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
.Property Address:
_ c�tio�Ce
Owner•
Date of spection `— 4 4
SITE EXAM
.Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water-17 feet .
Please indicate(check)all methods used to determine the high ground waz-r elevation:
Obtained from system design plans on record-If checked, date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators, installers-(attach documentation)
17'Accessed USGS database=explain:
You must describe how you established the high ground water elevatio-ti: �p
�.rf ByjQ �40"w �f i
C7* G/,S• �S
t y
11
Permit Number: Q Date:
Competed by:
HIGH GROUND-WATER LEVEL COMPUTATION '
Site Location: 5la�/a1aG �i`� �l/ d.L' Lot No.
Owner: Address:
Contractor:_ L�1� 1 � ��J`, .Address: yJ��d!
Notes:
STEP 1 Measure depth to water tole
tonearest 1/10 . ............................................................................... .Date
month./day/Year
i
STEP 2 Using Water-Level Range Zone
and Index Well Map locate
site and determine: %
OA Appropriate index we L................................................._
�B Water-level range zone .....................................................
STEP 3 Using monthly report "Current
Water Resources Conditicns"
determine current depth to
water level for index well .......................... �Z J
' month/year
STEP 4 Using Table of Water-leve3 Adjustments
for index well (STEP 2A), current depth
to water level.for index \&ell (STEP 3),
and water-level zone (STEP 2B) (�r
determine water-level adjustment ..........................................................................................
STEP' 5 Estimate depth to high.water
by subtracting the water-
level adjustment (STEP 4)
from measured depth to water �Z o
levelat site (STEP 1) ............................................................ ................................................
Figure 13.—Reproducible computation form,
15
i
TOWN OF BARNSTABLE aw
LOCATION g3 zt- SEWAGE #
VILLAGE G—� ASSESS O 'S MAP & LOT
SNSn6='�QS. NAME&PHONE NO.
SEPTIC TANK CAPACITY IOCa� iT'UtJ '.
LEACHING FACILITY: (type) (size) X
NO. OF BEDROOMS
BUILDER OR OWNERQUi
PERMITDATE: 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
within 300 feet of leaching facility) Feet
Furnished by
1'ec
3
V�
~LOCATION SEWAGE PERMIT N0
VILLAGE
INSTALLER'S NAME & ADDRESS
�-I_ V t�5ca\� '�. �6 ,
m-sS4d1nS m6- ��s
R U I L D E R OR OWNER
CI mop,'Va t vti
c,
IIC DATE PERMIT ISSUED
O
DAT E C 0 M P L I A N C E ISSUED
t
C "
C 3
Q 1
THE COMMONWEALTH OF MASSACHUSETTS
Application is hereby made for a Permit to C nstruct (LI/Or Repair an Individual Sewage Disposal
S Y s t7 a it;
-so:
... ............ ..�LA........ --- _e ...L2 YC.............................................
DOw Address
.-r-Tic-q1t........................... . .............................. e........................................................
Installer Address
Type of Building - Size Lof;q.21_�......Sq. feet
Z Other Distribution box Dosing C,
17
Percolation Test Results Performed by.... V-ro /A,
0. minutes per inch Depth of�-_Zest Pit_ DeptbAo ground water
Test Pit N
44 Test Pit Nc . ...minutes per inch Depth of Test Pit..................... Depth to ground water. .....
-----------------------
'--'--'---''--'' -'-----''--'—'-----'-_-----r----'-'----------
' g __-__.
The undersigned agrees to install the afozedescribed Individual Sewage Disposal 8yoternin accordance with
No......................... Fas..............................
THE COMMONWEALTH OF MASSACHUSETTS
- - BOARD OF HE L
i ..... .......OF....
Appliration for Disposal Works Tontrnrtion Vrrutit
Application is hereby made for a Permit to C. nstruct ( or Repair ( ) an Individual Sewage Disposal
Sys:t7 at
............112 L-Lik,dn..A..1.......
4
r --------
.............................
Locatiorn•• Ad.0ess
Owner Address- ...............
--........ . , .z:�. .........................................................
Installer Address
Type of Building Size Lo j f..7._....Sq. feet
�-� Dwelling—No. of Bedrooms.........5----------:......•-.___ ------Expansion Attic (40 Garbage Grinder fito
'4 e� Other—T yp of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
d ...................................................... Y. ,
W Design Flow.--...... ... .....................gallons per person per day. Total dail flow..........___.:.: gallons.
Other tines
------ ...
WSeptic Tank—Liquid.capacity f0-00gallons Length................ Width................ Diameter.....---........ Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
3 Seepage Pit No..................... Diameter..:,:.............:. Depth below inlet.................... Total leaching area.........._.._...sq. ft.
Z Other Distribution box ( ) Dosin0-4 g �}( )
a
Percolation Test Results 01-1
Performed by.... t " :.� . .,I r" /v ':.; Date..- � '..._. ..
Test Pit No14 . lid+ M> minutes per inch :Depth of' est Pit..... ,� - Dep o ground water _-/.
fs. Test Pit o. ... minutes per inch Depth of Test Pit... ........ Depth to ground water.9,� � ...
-� ---•---
D Description of Soil..... ""s Ceti � °d_,
--...------•--•----•--------•--...-------•-•-••..................••--
c., ------------------------------- '
-- ---••--• • •------•-----•-----•--•.................•---
x -•-••--•....................••-•----- -•-•-•----•------•-•-•-•......•----•......•--............-•-••----•--••-•••------------•••-•---••---•---------•---•--------•••--•-----•-•---••-•-••••---••-......
U Nature of Repairs or Alterations-Answer when.applicable.......................................--.........._..........................................
•-- ---••-•-•-•---•----•-•.................•-•-•••-•-•-•---•----•••----•----•---•-•••-•••••----•••--..........................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code—.The undersigned further agrees not to place the sys em '
operation until a Certificate of Compliance has be ssued by the,card of healt
- Signed.. .. ..,. � ,,. .r�.! �": ............................ ! ... ........ _.
Application Approved By--•..--• --- --• ---•_--- ... ........... Date
......•......••... Date
Application Disapproved for the fol ing reasons:.....:...:..::..........:.............................••------_-•------- ..........._
....•...------•-••--•----------------••------•--...--------...--------•...------......------•--•----.::.......----------....------------•--••-------------------•--------------------------------------•-
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEAL/TFJ
... ...
(9rrtgf irate of fjoutplittnrr
THIS IS TOr..ARTIFY, Tlp; the Individual Sewage Disposal System constructed ( r Repaired
by ( )
Install --------
has been installed in accordance with the provisions o TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No......................................... dated............-- .....-----................_...
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRII D AS A GUARANTEE THAT THE
SYSTEM WILL FU CT ON SATISFACTORY.`.
DATE............... a..�S_ .�.:�...........----•------------.... Inspector................----=•. • ---------- ..
THE COMMONWEALTH OF MASSACHUSETTS
.,, BOARD OF HE L
........tL ti-In...............OF....._.. v�
{ ..... .
No................ FEE .......
Disposal lvo4w, Tonstr rrmit
Permission is reby granted._C.."L t ..: _ ... €- G -•---...----••--•......................................:.....................
to Construct ( Rep it g( ) an)Individua Sewage Disposal System
at No.--••- •0-- .-( C±.f/1 .......- i:_- f��'4 J .
- ......
Street
as shown on the application for Disposal Works,Construction Permit No.......5 /Dated.._.. ----- ._____.......+'
.............•-•••---....................
B rd'oTHeaIth
DATE.........ta_.... .3 `.4U..-••••-•--7---•------------------•----:.
FORM 1255 A. M. SULKIN. IN'6 BOSTO.N
A.
12
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�r tl o� � '1 N07 l9SSa.rrty LoT
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/ ALBERT r.� � ROB EFT
iB.
n MURSE
E!0. 1UsyI
No.
1PFctstE
Cli L E G E/D
EXISTING SPOT ELEVATION 0%0 CERTIFIED PLOT PLAN
EX19TIN0. CONTOUR --- 0 ----
FINISHED SPOT ELEVATION L g T 3 0 V1 q 1 i)i; !-t w/j ,(
FINI$1HE,D CONTOUO ___ 0 _ � ', r, j ,;` ., 1/! t L
NOTE: The location of any existing unde_ r�;_ound sewerage, 1N
r
wells, or other utilities shown on t}-is plan is approx-
imate only as determined from records and/or verbal SAJIB
information—The contractor is responsible for 'therZ4�
verification of the existing locations in the field.. SCALE- /"= ��?� DATE ,
"'I.DRE06E ENGINEERING Co /N if
CLIENT.
�. I CERTIFY THAT THE PROPOSED
EGISTERE RE013TERED JOB NO. `�2 BUILDING SHOWN ON THIS PLAN
CIVIL I LAND I A � � CONFORMS TO. THE ZONING LAWS
ENO NEE RV DR. OF BARNSTABLE , MASS._
712 MAIN STREET CH. BY. ' /3, —
HYANNIS, MASS. SHEET OF 2_ A E REG. LAND SURVEYOR
I
NOTEE/TXG'R THE SEPTIC TAN�C OR
�D FT. MIN 4E,qc.�,i/�G P/T A/tE MORE Tt��1/t/.'/2"QFLOW _
" !rRA DES 24'411A METER CO/yCR
%O Fr j•9%N SNALL 9F BRDuGHT To GRAOE 1/ EX77,4ZA:
< ' 4.'PVC P/PE
. • . ';: CpA/CRETE �` � NEAYy CA ST /R {iER Oiv_ GO S/•, L BE+AL ,USED
All,". PJ7' JF/JV ORJVZFWA Y'
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1:. SC3/ED u[i 40
PKC. P/PE 3 /OO-0 • •. o D/ST. yy,4 SXFO ST�,,YE
/rT JSEPTIC TANK Y BGX • i i �. ; *•�* 32
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• 1 • • i • • •• • t Rio • • -
V r • • • tta • 1< • • •• • 0 t
_. • /5`/ x 2 = �7�' i.a. � • s • • .• •'•• • � �•� PRECASTSE�A4GE.
;.� J1. 3 •r �o =_ I • •` • • • • • • • • • • e P/7DRE4V/V_
lJ�/YPJCT l•LEY.4T/DNS Prr c�ngc��y
,,VVEg.H 7' A7 QU/lD/NG � ��� FT G "3 ld
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EFT .SEPT/G'. TANK i 47.5 fT: <i :.
OU74ET SEPTIC TANK 4T '' FT` - u TER TiIQLE
INLET OiSTR/DV71ON BOIL SECT/ON 4F' ' GRDIJNO MBA ,
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3 v Y SOIL TEST 0/ SO/L 7ES7,*2
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T TAL E1TJM�'r'E -
VuAfaze t7F I.-ACNJNI. PITS l f-ELEY. rE[RY, PATE OR, SOIL TEST
SJDE 4rA CHI NG PER.PI7- SQ. F7 r RpSULTS h/ITNESSED dY
O=Z•
JOTrOM LEACHING PER PJT 1 r Sq. FT LcJJ#Hl •g . �'EItCQL.4T/OJ1► RATEAt/
07AL l EACHIN E G ARA. •2-1-?4 LA t[
SQ. FT. Sr/8S0✓L ~: *W CO _ X.f IKG'y
T/ON RATE 2 T_H'`j MI:.
4ESERYE LE.4CN/MG AREA Z L,4'
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f 7t2 MAIN S
m` No.10951'�4
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