HomeMy WebLinkAbout0059 OREO LANE - Health 59 Oreo Way
246-042 Centerville
No. 4210 1/3 ORA
Pendaflexe
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COMMONWEALTH OF MMSACHIJSE17S
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTLO.N
ED
JAN 1 3 2004
TOVAN OF BAr.NSTABLE
HEALTH DEPT.
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM Z/1
PART A MAP T
CERTIFICATION PARCEL , aQ) 2- ,
Property Address: 59 Oreo Lane i' L07 _
Wu C.l✓ ��
Owner's Name: David Crean
Owner's Address:
Date of Inspection: /'"
Name of Inspector:(please print) William _ • Robinson Sr.
Company Name: William E. Robinson Septic Service
Mailing Address: P O Box 1089
Centerville, MA
Telephone Number:-m 8 l 7 7 5—8 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 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:
asses
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: �� , � ate,,..,, � Date: ' r0
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 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
****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 6/152000 page I
f
Page 2 of 1 l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued).
Property Address: 59 Oreo Lane
W.HHyannisport, MA
Owner.
Date of Inspection:
Inspection Summary: Check A,B,C,D or E I ALWAYS complete all of Section D
A. Syste Passes:
1 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:
B. Sys em Conditionally Passes:
e or more system components as described in the"Conditional Pass"section need to be replaced or
repaired. he system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer y ,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please
explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound,c xhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the
existing ta ik is replaced with a complying septic tank as approved by the Board of Health.
•A metal eptic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating at the tank is less than 20 years old is available.
ND expla :
servation of sewage backup or break out or high static water level in the distribution box due to broken or
obstruct pipes)or due to a broken,settled or uneven distribution box.System will pass inspection if(with
approva of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain
The ystem required pumping more than 4 times a year due to broken or obstrvx1cd pipe(s).The system will
pass inspect on if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is n=vcd
ND explai
Page 3 of 1 I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 59 Oreo Lane
W. Hyannisport, MA
Owner: David Crean
Date of Inspection: 1- -'
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 fa ing 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
ystem 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. Syst m will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system i functioning in a manner that protects the public health,safety and environment:
_ e system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surfa a water supply or tributary to a surface water supply.
e system has a septic tank and SAS and the SAS is within a Zone I of a public water supply.
he system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
e system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
priv to water supply well- Method used to determine distance
'•T is system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bac ria and volatile organic compounds indicates that the well is free from pollution from that facility and
the resence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
fai a criteria are triggered.A copy of the analysis must be attached to this form.
3. Otl er:
3
Page 4 of 11 '
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 59 Oreo Lane
W_ HYanni Gpart., MA
Owner: Davi c3 C'rpan
Date of Inspection: -JTL'
D. System Failure Criteria applicable to all systems:
You ust indicate`yes"or"no"to each of the following for all inspections:
Yes o
Backup 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
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%day flow
_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
y portion of the SAS,cesspool or privy is below high ground water elevation.
y portion of cesspool or privy is within 100.feet of a surface water supply or tributary to a surface
water supply.
y portion of a cesspool or privy is within a Zone 1 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 eater
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.)
(Yes/No)The system fails. I have determined that one or more ofthe 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 ystems:
To be consi Bred a large system the system must serve a facility with a design now of 10,000 gpd to 15,000
gpd•
You must ind cate either"yes"or"no"to each of the following:
(7lte followin criteria apply to large systems in addition to the criteria above)
yes no
_ _ the ystem is within 400 feet of a surface drinking water supply
thew' l_ _ lystem is within 200 feet of a tributary to a smface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Z " e 11 of a public water supply well
If you have swered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Secti n D above the large system has failed.The owner or operator of arty large system considered a
significant thr at under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The s -stem owner should contact the appropriate regional office of the Department.
4
Page 5 of 1 I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST.
Property Address: 59 Oreo Lane
W_ HWAnn i apnrt MA
Owner:
Date of Inspection:
Check if the following have been done.You must indicate`yes"or"no"as to each of the following:
Yes No/
Ll Pumping information was provided by the owner,occupant,or Board of Health
v Were any of the system components pumped out in the previous two weeks?
t/ 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?
l/ Wcre 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 back up?
Was the site inspected for signs of break out?
v _ 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
te mainnance 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
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 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 59 Oreo Lane
W. Hyannisport, MA
Owner: David Crean
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):.36 6
Number of current residents: 0
Does residence have a garbage grinder(yes or no): kO
Is laundry on a separate sewage system(yes or no):1,0 [if yes separate inspection required]
Laundry system inspected(yes or no): v
Seasonal use:(yes or no):/i/
Water meter readings,if available(last 2 years usage(gpd)): 2 0 0 2—6 5, 0 0 0
Sump pump(yes or no):/- 2 0 01 —4 8, 0 0 0
Last date of occupancy:
COMME CIAUINDU TRIAL
Type of es blishment:
Design flo (based on 310 CMR 15.203): gpd
Basis of d sign flow(seats/persons/sgft,etc.):
Grease tra present(yes or no):_
Industri4vaste holding tank present(yes or no):_
Non-sani waste discharged to the Title 5 system(yes or no):_
Water m ter readings,if available:
Last dat of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part oMe inspection(yes or no)�q
If yes,volume pumped:_gallons--How was quantity pumped determined?
Reason for pumping:
TYP F 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 the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no):4
6
Page 7 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 59 Oreo Lane
-W. Hyannisport, MA
Owner• David Crean
Date or inspection:
IlU� DING SEWER(locate on site plan)
Dep below grade:
Mater Is of construction:_cast iron 40 PVC_other(explain):
Distan a from private water supply well or suction line:
Comm nis(on condition ofjou►ts,venting,evidence of leakage,etc.):
SEPTIC TANK:_(locate on site plan)
Depth below grade:—�
Material of construction:othcr(explaut _ fiberglass—concrete_metal _polyethylene
_ )
If tank is metal list age:_ Is age confirmed-by a Certificate of Compliance(yes or no):
certificate) ► —(attach a copy of
r /
Dimensions: �� e
Sludge depth: —;I_ " I
Distance from top QQf sludge to bottom of outlet tee or baffle:
Scum thickness: 0 /
Distance from top of scum to top of outlet tee or baffle:
Distance Gom bottom of scum to bottom of outlet tee or bathe: Lf1
How were dimensions determined: d &y✓ 1 oa,
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as rclatco to outlet invert,evidence of le kage,eV.):
e�eel .�
� L
GREA E TRAP:_(locate on site plan)
Depth b low grade:—
Material of construction:_concrete._metal_fiberglass_polyethylene other
(explain
Di lensi ns:
Scum thi kness:
Distance from top of scum.to top of outlet tee or baffle:
Distant from bottom of scum to bottom of outlet tee or bathe:
Date of ast pumping:
Comme is(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as relat d to outlet invert,evidence of leakage,etc.):
7
Page 8 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Properly Address: 59 Oreo Lane
W_ Hyanni sport, MA
Owner: lea zi rl Crean
Date of Inspection: — o !
TIGIIT or OLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below ade:
Material of c struction: concrete metal fiberglass_polyethylene other(explain):
Dimensiorcondition
Capacity: gallons
Design Flgallons/day
Alarm pre :
Alarm levarm in working order(yes or no):
Date of la
Commentor;
and float switches,etc.):
DISTRIBUTION BOX: V(if resent must be o ened locate on site plan)
P P )( P )
Depth of liquid level above outict invert:
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,
g o ,etc.):
PUMP HAMDER: (locate on site plan)
Pumps in orking order(yes or no):
Alarms in �•orking order(yes or no):
Comment (note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
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: 59 Oreo Lane
W. Hvannisport, MA
Owner: David
C n_
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation'not required)
If SAS not located explain why:
Type
leaching pits,number:L
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 pondin„damp soil,condition of vegetation,
etc.): / _
CESSPO LS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number an configuration:
Depth—top f liquid to inlet invert:
Depth of sol ds layer:
Depth of sci m layer:
Dimensions f cesspool:
Materials of construction:
Indication o groundwater inflow(yes or no):
Comments( ote condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
PRIVY: (locate on site plan)
Materials f construction:
Dimensi s:
Depth of solids:
Comme is(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 59 Oreo Lane
W. H annis ort MA
Y U
Owner: David Crean
Date of Inspection: -O
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.
/ J J
b dY
VO
0
10
Page l l of l l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 59 Oreo Lane
W. Hyannisport, MA
Owner. David Crean
Date of Inspection:
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water o`�.a 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:
Observed site(abutting property/observation hole within 150 feet of SAS)
Chec ed with local Board of Health-explain:
Ch ked with local excavators,installep.(attach documentation)
ccessed USGS database-explain: -a 5
You must describe how ou�establi cd the high grow d water elevation:
.5 J
11
y
Health Complaints
0:7-Jan-04
r
x
Time: ,10:30:00 AM Date: 1/6/2004 Complaint Number: 17213
Referred To: DAVID STANTON Taken By: DAVID STANTON
Complaint Type: 'TITLE V , SEWAGE
Article X Detail: ILLEGAL OPERATIONS
f,
Business Name:
Number: `59 Street: Oreo
Village: CENTERVILLE Assessors Map_Parcel:
Complaint Description: Completed a septic inspection for a property
transfer. Is concerned because the current
owners have a stone driveway over the septic
system and park vehicles on top of the septic
system. The system would fail as is because it
is an h-10 septic located under a driveway. The
owners want to know if the system could pass
inspection if they put railroad ties to block off
the septic system so no one can drive over the
septic.
Actions Taken/Results: The owners came in questioning why this would
make it fail. DS and DM spoke with them, and
they are not going to use the area for parking
anymore, and are going to install rail road ties
next to the septic so that people cannot drive
over or park on the septic system. Bill called
DS on 9/6 @ 3:30 pm wanting to know if he
could pass the system, as they put up railroad
ties on top of the system, and they can still drive
over part of the system. On 1/7/2004, ds met
Bill Robinson at said location. The railroad ties
were placed on top of the septic system by the
owner. Bill put a stake on top of the septic tank
cover to show its location, and moved the
1
Health Complaints
07-Jan-04
railroad ties so that vehicles could not drive on,
or park on the septic system. At the conclusion
of the site visit, Bill passed the septic system,
as at that time, the railroad ties were placed in
the correct location. Bill is not responsible if the
owners of the property move the railroad ties or
park on the system and it collapses. Bill
outlined the edge of the tank with spray paint,
and left a steak at the cover of the septic tank.
The H-20 loading under a driveway is required
under 310 CMR 15.226"Any tank installed in a
location where there is the potential for vehicles
or heavy equipment to pass over it shall be
designed to withstand an H-20 loading."
Several photos in the residential file showing
the railroad ties in the correct location so that
vehicles may not drive over the septic.
Investigation Date: 1/7/2004 Investigation Time: 10:30:00 AM
2
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LAND SURVEY AND CIVIL ENGINEERING ASSOCIATES
ALL CAPE SURVEY CONSULTANT
LAND SURVEY AND LAND USE DESIGNS
172 EAST FALMOUTH�HIGHWAY
f EAST FALMOUTH, MASSACHUSETTS 02536
PHONE 548-4255
I CHRISTOPHER COSTA P.L.S.
October 26 , 1981
TOWN OF BARNSTABLE
Heatlth Department
Box 534
397 Main Street
Hyannis, MA 02601
M ,o
Ladies & Gentlemen:
RE: 10reo Wa . Sean Daley
(Plan da ed 9/1 /85 W iam Lieberman PE )
The septic system on the above referenced lot, I find, has
been installed in compliance with the plan.
If you have any questions, don' t hesitate to call me. ,
With kindest regards,
QJi14 Co a, .L.S.
John Jacobi, R.S.
CC:ko
CC:Ronald McGaffgin
now-
Fig......... ......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
ouP . ..................oF...:. .R�JS'T.A�i3C-._...__._...--•--
Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal
System at: /
42 oe� ,CAE - ._.,, ....
--- -=�° ----------------------•---........................-••-•.................... ------ ---...e!ui1i�...-------•-•--.......•--......--------
L ation-Address or Lot No.
� L E _...
G�a ownerAddress' �................. .CGJ..ir�.t �............................. ------------------.------.-----Add-----.-..-..-...-.--....._--------------•--.--.
Installer
d Type of Buildin� Size Lot._�O O__O._...Sq. feet
V Dwelling 2 No. of Bedrooms......................................Expansion Attic (IJo) Garbage Grinder 00)
Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
a Other fixtures ------------------------------- --
W Design Flow.............5..-�?`�.. ..................gallons per person per day. Total daily flow----- .>.10......................gallons.
WSeptic Tank—Liquid capacitylQoQ.gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No........ Diameter......(p......... Depth below winlet............... Total leaching area..2 A..'--�.....sq. ft.
Other Distribution box ( !/� Dosing tank ( ) /Z a F S TON E
z 1 ' 1
'-' Percolation Test Result Performed by79.4',,'T:. 1�... ..1 �`...................... Date...... ��Z `` ........
tF
04 Test Pit No. I................minutes per inch Depth of Test Pit----t_�.......... Depth to ground water._._�.l ..............
1-4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water......_.................
-- ------------------------------------------------------------------------ ---- ------------------------------------
0 Description of Soil.........e.':..�. . I�...--�-. a.-----------------------•------.................------.._..............---------•----------
.......................?..'.-.1. ....... .... e.-D ..Spa
W ------••----. -------•---------------------------- ............................................................. -A
Nature of Repairs or Alterations—Answer when applicable....... ^ _?z�.. ---�..�' ^�-...fj?�?.�. .. .
---• ---
i
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitaryt� cicb
Th unde ' ned further agrees not to place the system in
operation until a Certificate of Compliance has b t d o alth.igned..... •-- ......................................................... ....--•---•-•--------------_.---
ate
ct
Application Approved By............. 1�-��-
Date
Application Disapproved for the following reasons----------------------------------------------------------------------------------------------•......-•----•--•-
........................................................................................................................................................................................................
Date
PermitNo... ..-•-•--....---••---••-. Issued---------------------.................................
Date
Y
No. ..88 Fay ....._
THE COMMONWEALTH OF MASSACHUSETTS
-� BOARD OF HEALTH
v u . oF. t�-, t•��3
Appiirtttion for Disposal Works Tonstrurtion rrrutit
Application is hereby made for a Permit to Construct ( () or Repair ( ) an Individual Sewage Disposal
System at:
//
r ........... -Address ............... ..............................................or Lot.No: ........................................
Address
Installer Address
Type of Building _ Size Lot... ....Sq. feet
1-4 Dwelling No. of Bedrooms........... ........:....................Expansion Attic (/ O) Garbage Grinder (IJG)
a Other—Type of Building No. of persons............................ Showers yP g --------------------•---••-- P ( ) — Cafeteria ( )
Other fixtures
W Design Flow............. �:_._................gallons per person ZZ
per day. Total daily flow......=_.:= ......................gallons.
WSeptic Tank—Liquid capacity.l l q .gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No........I............ Diameter....... 2 t)
pag � ._.... Depth below i et._...4_......... Total leaching area. ...sq. ft.
Other Distribution box Dosipg tank ( ) ? D ts T),j c
'-' Percolation Test Results Performed by... �: ?�`� -� .. .. .,� ..................... Date...... a.!- 1 .�1�
I� ......
Test Pit No. I......Z.....minutes per inch Depth of Test Pit....�.r�_........ Depth to ground water....�.�:...`'.-........
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
94
D Description of Soil.. ��,........................................
-.r�-�---f(-P;.�•-f �,-�-�=--"��''{.f�..--------• ...................•-•--•----•--...---...........-•---...........----•-----
,... .. :.. ....
U ......................................... ......[..............................................._✓ ....�.....--....................--.....................--...-:............................--..
......................................................................................................................... ___
.--,•r� -.
Nature of Repairs or Alterations—Answer when applicable............. ..i' ' - �=r + �
-----------------------------------------•--------••------•--•-•-••-•-• ..._.........
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—.Th unde ' ned further agrees not to place the system in
operation until a Certificate of Compliance has been �b r 14)0�alth.
Igned.. .......................... ..........................
D to
Application Approved By............. -••--<2.1................ ------•---•................•-•- ........... b a:.......---
Date
Application Disapproved for the following reasons:.........................................................................................................._....
.........................•---•--...........--------.......--------..........._..------••----.......-------•-----•-------•----.......-----------------------------•- ....._
Date
PermitNo....�� ..................._.... Issued-.....................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....�J t c� �J OF.........r ?> // G. C
... ........................................................
Trrtif irtttr of Toutpiittnrr
THIS IS� CE,�TIFY That the Individual Sewage Disposal System constructed (x) or Repaired ( )
by•-•-•........ I ......_ !�e: - `=- -==�'.�. ._ ��...... . ..................... ..... .................................. ......._— ..... .. ...... .._.
44 Ind alter
at.................................2..�......... . .... :
}`.� -•--...---••--•----•-------•---.........•-••---•-•--•--••---•---_. ...-•-•-......•--•--
has been installed in accordance with the provisions of 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 CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.......... '? -....'..-' �V&.......................... Inspector.....
. ... _ ......_.__...-•---------THE COMMONWEALTH COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
No. �" / (. ... v.. .............0F...... ��! -..!..�..... ram..........................
Disposal Works (�unstrurtintt f truth
Permission is hereby granted.............. ,.<Lk!`':-:._...(. r. .... ..........._..
to Construct,( X)�or,7epair- ) an Individual Sewage Disp� System
at N.o.....f. `�...........-••.... ......_... CC'Q......... n.......
�:'.�n.>� ..........
Street g, -gs /
as shown on the application for Disposal Works Construction Per ' ,_No.................... Dated..... 1. 1
...........
/• _._._� '•L _. Board of ............................................
. ...................•-.......-•-•••--••; ^ r Heal
DATE......
:.... . .. ?'j.........................
FORM 1255 A. M. SULKIN• INC.. BOSTON
't f;y
LUa T�,z A ,J
j
STEP 1 Measure depth to water table-
to nearest 1/10 ft.
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6 /iz
---- - --- date
STEP 2 Using Water-Level Range Zone
and_Index Well Map locate
site and determine:
A) Appropriate index well Tsh/�9
B) Water-level range zone . . . .� . . . . . 7' z
L � J
, STEP
3 Using monthly report"Current
Water Resources Conditions"
determine current depth to l' S
water level for index well . . . . . . /P4�
mo yr
STEP 4 Usio'g Table of Water-level
Adjustments for index well
i (STEP 2A), current d&pth to
water level for index well
(STEP 3) , and water-level
zone (STEP 2B) determine �' b water-level adjustment C- -
STEP 5 Estinate depth to high water
by subtracting the water- _ .
level adjustment (STEP 4)
from measured depth to water fpA9 ,
level at site (STEP
a •
r
,.+.�..+w...-.tea• ._:.. - :...- :..
SOIL LOG
NO. 1 � - NO. 2
SITE PLAN Z"I i
2 - -�
3
e .. TOP OF FOUNDATION EL �0 —,- g �
93 Z
8 --- -�-�
I
<._ � a �
9
100,
10
C
� .
,A• """ 0 • • ".S_.' ..i I N.E L. �...i.f--`""� ✓"'�r I N.E I. .—.� I V P 1, ,,.'. ♦ .� -t ��,�.�}l M y �I �
f 2 L�DYL F1 WA,,NC.T� ���� t _
1 �� / 11
s e _ _.r. CL J12
• j � - �j — —
.• INJL
`'
?• 13
O/B W/ fi SUMP ,r . ; 14
:. / 7-0
. . .
,e
4- LIQUID LEVEl. ;
i • _ :'.; __ i _ _ -� 15
PERC TEST RESULTS
EL �J
�, _ ___._. � PERC RATE :
PRECAST SEPTIC TANK WITH �--___... _
WITNESSEDBY ,� __
CAST IN PLACE INLET AND
i
BOARD OF HEALTH
OUTLET T `S PER TITLE V
SIZE Z 0 0 0 _
� �r��c n��r �__ �::.n.�.►r�a1 �-� ��'s t lam_ L)kiK '
PROFILE OE PROPOSED SEWAGE SYSTEM
-- `_r , 1� _--_ REGULATIONS AND D��
J Sj,YSTEM DESIGNED BY THE TOWN OF q
n�.u�- -
.. ; � � SZ ra' r�➢i7 tf
STATE TITLE V FOR SUBSURFACE DISPOSAL OF SEWAGE . SCALE 1/4' = 1 0
L A-
1. ALL PIPES SHALL BE SCHEDULE 40 P,V.C. SEWER PIPE ` o _ r7x� ' _ _y x _,w--� W
2. ALL PIPES SHALL BE SLOPED 1;4 `° PER FOOT EXCEPT FOR (}(}
d i
THE FIRST 2 FEET OUT OF THE O / B WHICH SHALL BE LEVEL
,
. DESIGN FLOW ___ : . BEDROOMS AT 110 GALDAY PER BR. 3: '?w GAL/DAY
SEPTIC TANK SIZE . _?_ X GAL .
USE __-_- _ GAL. '/_ GARBAGE DISPOSAL
LEACHING SYSTEM . USE ��,z� <. ,�::T l-�A4-14/ti4:' ✓� L�`�r e x4{ F r_ .r
� EFFECTIVE AREA : SIDE
B 0 T T 0 M _-_z"
i{ TOTAL FLOW
TOTAL REQ '@ FLO1N .:= _ X � _ -W1 _. GARBAGE DISPOSAL
RESERVE F L 0 W ti_3.- G A L ' D AY
REFERENCE PLANS r _Z 3
APPROVED VE BY :
O A R O Of . H ALTN _ _ � __ - -
�. 1
. E
OAT E /T
S/
PROPERTY OWNER • 5 <twJ P . DAL-E
:
c, a_.. ._
LL r--7—
_Nil
�
� t
..ti - ? _
�aTATi ,Lt
x a
9
SOI L LOG
1 S a
,
!!I
SITE PLANNO NO Z
`
} _R 4 r.. ,y C?AhF v lv'r` 1cL r r/j i7C) 0
•
_
.ri
zz�
�.
,r �."1 �
3
4
--~ TOP OF FOUNDATION EL.: t5,� G _
7 _.._. ..._. i
B r
8
10._.._y.. R d .r..:..fL."...R___AC..:..-t:....!-�.1.._.-s-'Y---' — Cy / •-,..,."'• ,."`__- .,.......,..,., ... .•-.-......-.4.-i•,.... ..r.--._+1 10
jr
IN.EL. IN E
a•—
IN.EL l I/�
h`.a Dl B W 1 S", sump � '- d 13 LIQUID LEVEL14
Is;Ta
oi,4 .
PRECAST SEPTIC TANK WITH
PERC TEST RESULTS
PERC RATE ____.. _
CAST IN PLACE INLET :AND { WHITNESSED BY.
OUTLET T .S PER TITI:F 1,
BOARD,,r ,s
0
SIZE : Ut f _ L q� _._
,TH F HE
.,.
DATE.
r
17
1 t r�
Tab
so
tj
E r -
PROF I LE OF PROP SIB D S "' E SYSTEM . � � 7.4 �N , y �. . � Lf . a
if j
-
SYSTEM DESIGNED BY THE TOWN OF REGULATIONS AND `
t.-.. .,.
STATE TITLE FOR SUBSURFACE OISPQSAL OF SEWAGE . SCALE 1/4"= 1 ' O. ,z r __. �
Z +o
,
Ik
..
N . B . � � ;- �_ 4AOF AT
� .
I r
1. ALL PIPES SHALL BE SCHEDULE 40 P.V.C. SEWER PIPE i0o
2. ALL PIPES SHALL BE SLOPED 1/40" PER FOOT EXCEPT FOR
j
THE FIRST 2 FEET OUT OF THE Oil WHICH SHALL BE LEVEL
FLOW 1: BEDROOMS AT 11 GA1. 111 ` PER BR
�. DESIGN � � 7
, GAL/DAY
r
SEPTIC TANK S I Z E X -
,
1'
USE _ .
t AL. Wl_._�__T GARBAGE DISPOSAL
- � -
x r7•F
LEACHING ���. 4 � � �- .��
SYST�I� . USE . .
1A7f Tir ? r
EFFECTIVE AREA . SINE - 2 s = to , _ ; FWilli imil
BOTTOM
:1 R Y
TOTAL F LOW .
I TOTAL RED D FLOW �� ! GARBAGE DISPOSAL -
X -� W
RESERVE FLOW 3 -71
w;.� 1 �
77
REFERENCE r Y
•
,
APPROVED BYs
� A D D HEALTH
DATE,
R WEB :
I AN
s t`^
o sk r!XOy_.tS
IWI
it-AG F `W�_X T..)vJ�:�L }�\}Via..
LOT- l-_
jj
,
,
t
F
1 M
^` to rw.yy, - .... ... -. ».: .:......................................... .... .. ......:<, -_...-..•.._.. a ..v-...n. +..,... :..., x.,.«. r I �T r. ♦.°^1T�
l
r