Loading...
HomeMy WebLinkAbout0697 SHOOTFLYING HILL RD - Health 697 Shootflying Hill Road Centerville A= 192 060 Ocyctea UPC 12534 No.2-153LOR ,J` MAGTINGS.8M Fps.. .. THE COMMONWEALTH OF MASSACHUSETTS -BOARD OF HEALTH 1J �2.cJ .......... OF.......................................................................................... Appliration -for Uiipnsal Works Tonstrurtiun Vrrnti# Application is hereby made for a Permit to Construct ('�) or Repair ( ) an Individual Sewage Disposal ..................................... 1 Location-Address - - :or Lot No. • - ^ t• _� ------------------------------- Address ... .::................ er Address c Installer Address :t Type of Building Size Lot.'2O �....Sq. feet ,.., Dwelling—No. of Bedrooms............................................Expansion'Attic ( ) Garbage Grinder `k Other—T e of Building ._..._. No. of persons............................ Showers — Cafeteria Pk YP g = P ( ) ( ) Other fixt l ------;���'W T------------------•------------i--•--•--•---•-- Design Flow__________________ 7< ..gallons perjerson$� Total dlY PQW............. ,:..:a...'.......=. g- ons. Septic Tank— _iquid capacity/� lons Length_.5?�.......... Width_, "_ /.o.. Diameter................ Dep __s....Disposal Trench—No. .................... Width..*.....::::.......Total Length.................... Total leaching area..:_.................sq. ft. Seepage Pit NO; ..___:�_..._..._.. iameter........./.�... Depth below inlet...... _ ...._........ Total leaching area... ! .7sq. ft. Z Other Distribution box (� Dosing to (JCo� �� 8� 4� / Date... a Percolation Test Results Performed by....:--- ._-•-•-- --__---_- r................ ,�..._......___..............�.. Test Pit No. 1.G'.2_minutes per inch Depth -of Tes Pit_.._...1 __. Depth to ground water..._7.1Z..._. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water............__.......... a •--•------•------- •-- ----------•-------------••. . . :..... o z -�`-`-l•-�••-•�'�`� ��'._-.%�`�` Description of Soil..©_"_.___l�_�.. /.............. .._. USl''�''�.a.. G/2.p✓ z- '.:.---•......................................••--•---.-.....--•--...----.........-----.............................---•.......... W = :_... ----------•----------....................................................................................................... ' UNature 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 iITL% 5 of the State Sanitary Co — The undersigned further agrees.not to'place the system in operation until a Certificate of Compliance h en issu by the of health: Signed... ....L ' Dae .......... . . ---••-•--- ate Application Disapproved for the following reasons:.................................... --...---.------•-----•'--................__•-•-•--•..:---•............._ ......................................-----------------------------------------------------..... ---------------------------------..--------------•---•------- ............................... r � Permit-No...............•--�-----..!._.Cd1.—�-•----.... Issued_:-----•--•----- . ....6--' ---........Date...... ate -• - ;% � � x ,� r �� �«��,�- Fps,......-� b 1 y� THE COMMONWEALTH OF MASSACHUSETTS t =":BOARD OF HEALTH plc°� -✓ OF......... .................... icJsT/S?l3E..fs' ^........ Applirtttion for Disposal Worko Tonsknrtiun jJrrtnit ,. /-` Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at: f e. 1 duo/rGL c , 27 Location•Address or Lot No. ................ ........................................................ .................................................... - ...................... . -- w er Address a . ........... yl ......_._.......•.. _...._._............._......... -........_.__....... Installer Address Type of Building . Size Lot............................ :'�......r............Sq. feet V Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder (t./c)e p`4 Other—Type of Building a yp g ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) a Other fixtures . WW Design Flow....................-----:•--------- gallons per person.Xp clay. Total day ow.--........._.r % --•-.•----......--gallons. WSeptic Tank—Liquid capacity/..__._gallons Length.U............. Width._�`•-.•-•••.- Diameter................ Depth-•----_•y-_. x Disposal Trench—No..................... Width. ......_...... Total Length.................... Total leaching area....................sq. ft. 3 Seepage.Pit No........ ...........,Diameter ......./.J... Depth below inlet......:= ........ Total leaching area.._.��_'sq. ft. z Other Distribution box (411) Dosing tank Percolation Test Results Performed by--------- ......................-•................ ..................... Date..-- ;--.--.....__........:;_. Test Pit No. 1.G.`-.-_..minutes per inch . Depth of Test Pit....... _.... Depth to ground water.....?. Z_....: 1 Test Pit No. 2................minutes per inch Depth of Test Pit........:........... Depth to ground water........................ x . ----�-----f'-t------------------------------r / - / � --.l--.-------------- --------- ----•-- ........... -----•--_O Description of Soil... ......_c?t? .-•---•---------------------•---•----- ----•---•--•--•-•----•--------. -•------------........................----------- W -••••-••-••-----------------•----•-•-------••------------•----•----•••-•-• ------••-.............................................. 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 hays lkn issue by the b ard`of health. Signed. /. a ._ t_,' . r�.�/.L..----.....,�....,.:_..�e�! ..../g Date Application Approved By.c �: ` .... : �..�. n� �,. U7 l � '.-- ,.r� Date Application Disapproved for the following reasons-.................................. ---••----••----••••---•-------......----•-•-----........---•-._..........._ --•--•.........................................;..`..................... . ....••--_._. :........----•---------------------••----------------- ---------------------------- ............. — �. Issued................ .... .......Permit No.•-••----•----`--------------�.- � •------... ~ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH - ..........................................OF...................................................................................... Trriifirtttr of Toutplittnrr THIS,IS TO CERTIFY, That the Individual Sewage Disposal System constructed f or Repaired by........�1. - ........:......... J ^ Installer at •-- n.C1 ---•- has been installed in accordance with the provisions�of-TI. F of .The State Sanitary Code as described in the application for Disposal.Works Construction Permit No......................................... dated_. 2�._ ..................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL fFUNCiION SATISFACTORY. ff {lt Inspector' ` ...... THE .COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Z ............OF..................................................................................... �. FEE.,..:... U Dispnsf Works T.a strurtion rrmit Permission is hereby granted v� --."��----------------------------•• -----------...............................•.... - at-, Repair t or a�(!:-: •Indivl 3)ail S\gag spo- --to System-•-----•------------------------ ----- - j ✓, ./,.. .� as shown one he application for Disposal Works Construction Permit No..................... �D'ated.:.._../__2��:���t'�....._........ ••-•-----•--__----1 _•------------------------------------------------------------------------------------------ - Board of Health DATE..........................................................................------ TOWN OF BARNSTABLE L�.)CATION Q 7 �'�lo XNr, SEWAGE # Ff—//-2- 4'- �TLLAGE Ge�il�l. "!' � ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. �—;T/ SEPTIC TANK CAPACITY /000 LEACHING FACILITY: (type) /ODU )p` (size) NO. OF BEDROOMS BUILDER OR OWNER PERMITDATE: /Z&0, K COMPLIANCE DATE: 3Mles' 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 o : cos rel A t3,. COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION t TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICAT/ION Property Address: 617 S/ivoT�Lria*,�//if/sty Owner's Name: �✓ir�c Li:t��i� Owner's Address: 4;7rr/u�T,G�rivL ftj/,e?� (cc-r 5123 9.3" P' Date of Inspection: Name of Inspector:(please print) � (�,o�x;✓G�/a�s.¢s Company Name: ay-Piers Mailing Address: c2,orgf-j ' e: p ��1�- — , Telephone Number: 7,78 ®.z--yS CERTIFICATION STATEMENT r I certify that I have personally inspected the sewage disposal system at this address and that the inform ion reported m below is true,accurate and complete as of the time of the inspection.The inspection was performed ba d 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 45.000).'The system: —./�a-qses Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: 11 Date: // a 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 6/15/2000 page I Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 7 Owner: 12 4.t gi 1Li yds Li�dB�2y Date of Inspection: S— Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _jZI 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. 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. 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: 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: 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: Title 5 Inspection Form 6/15/2000 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: j� et 7 �/weTf-��°i ///�✓ I/i'& Owner: i L t LlaI4 e- ,c r/ — Date of Inspection: 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 **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: Title 5 Inspection Form 6/15/2000 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1,9'7 S h aoTF 4 AV A/ /i AV?jA Owner: D�4mt/1PL inlr/,4 LrN E,ey 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 No Bckup 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 ogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or "aesspool w_ Li id depth in cesspool is less than 6"below invert or available volume is less than%day flow ired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number times pumped . _ _L.-I rportion 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 water supply or tributary to a surface water supply. t/Any portion of a cesspool or privy is within a Zone 1 of a public well. portion of a cesspool or privy is within 50 feet of a private water supply well. _sue�y 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.] AJO (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;ter o"to each of the folio (The following criteria apply a systems in additi o the criteria above) yes no _ the system is withinee of a ace drinking water supply _ the system is within a tributary to a surface drinking water supply _ the system is locatenitrog sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public supply ellIf you have answered"yes"touestion 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. Title 5 Inspection Form 6/15/2000 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: (e-1 7 Owner: Pgkc-L V. LiNV(4- L-fwol, Date of Inspection: /�V—O.�� Check if the following have been done_You most indicate`fires"or"no"as to each of the following: Yes No Pumping information was provided by the owner,occupant,or Board of Health ere any of the system components pumped out in the previous two weeks? c/ 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? Were as built plans of the system obtained and examined?(if they were not available note as N/A) JL Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? I _ 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)on the site has been determined based on: Yes no a/ 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 dis+ ^ce is unacceptable)f310 CMR 15302(3)(b)] Title 5 Inspection Form 6/15/2000 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Cr,(c- - �f,,.i�Ly/�/.-z%i/ G ✓/Z .z Owner: 'e L .r I-IAV,4- L1� Date of Inspection: 14/a//e S' 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): Number of current residents: .2-- Does residence have a garbage grinder(yes or no): A10 Is laundry on a separate sewage system(yes or no): &�;[if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no): 020o S/ ,/-oe s' Pater meter readings,if available(lass 2 years usage C' 7 ovo a z food Sump pump(yes or no):_A1,0 Last date of occupancy:--ly COMM'ERCI<AI.fINDfISTR IAL Type of eS`.;:s'°lishment: Design flow(based on 310 CM.R 15.203): gpd Basis of design f1 (swats/persons/sq,etc.): Grease tip (yes or 1€}): lodustHal wart:hoa r=erg t=:.� Non-sanitary waste ise red to the Title 5 system(yes or no):_ `dater meter reading I available: I ast Caste O T HER(de- rib-): C.FNERAT,IN TORMA'E` ON S Source of i-?formation:—( !/,P�/' SyYc� 7%�47- Was system pumped as part of the inspection(yes or if yes,volume pumped: g"aallons--How was qua= 3'pumped d€terrnined? Reasron for----mn:n,- gg��- F .�+p+7S�•� T Y E QV S 5 S 2 TilY9 eptic tanlc,distnbutlon box,soil absorption syste n `Ingle cesspool overnow cress-myol Privy _Shared system(yes or no)(if ye .attach previo:s; e-tion records,if any) Innovative/.Alto--native technology ?attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tig_ ht taik _Attach a copy of tice DEr approval _Other(desc.:ibe): Approximate age of all component;,r to Installed(If l:nown)and source of Information: Were sewage uddors Bete-u ed when arriving ut t-he site(des or m0l ���✓ 6 T itle 5 lnspec;`tion Forrn !15/2a00 Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 9 S/foo���i:►� �Li%/ l.6FiVT��✓/o/I��d?7J�3 Owner: n6�ti�r f ,j use% Qx�y Date of Inspection: BUILDING SEWER(locate on site plan) Depth below grade: 4k Materials of construction:_cast iron 4,10 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: oncrete_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: Ifz Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: -Z-e Scum thickness: i-"` Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: 44V�,-- ae,� 77004-5 Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invertqvidence of leakage,etc.): � nee GREASE TRAP:_(locate on site plan) Depth below grade: Material of constru on: =—metal fiberglass_polyethylene_other (explain): Dimensions: Scum thi ckness: Distance fro p o to top of outlet tee or bale: Distance om botto of scum to bottom of outlet tee or baffle: Date ast pumping. Co ents(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Title 5 Inspection Form 6/15/2000 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: (,.$7 Owner: L2,Wift -- Li,&a1 - Date of Inspection: l el yIe S TIGHT or HOLDING TANK: (tank 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: gallons 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.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet 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,etc.): PUMP CHAMBER: (local" loca I site plan) Pumps in working ord r(y or no): Alarms in working ord es or no Comments(note cond' n of pump chamber,condition of pumps and appurtenances,etc.): Title 5 Inspection Form 6/15/2000 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: (, Q ? A MAY A✓f / s�i� Owner: UI�eL L iN i¢ LiN L?E Date of Inspection: t !I El o s� SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type —L leaching pits,number:_ 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 ponding,damp soil,condition of vegetation, etc.): CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: _ Depth of sc ayer: Dimensions of ssp Materials of con action: Indication of water inflow(yes or no): Comments( to co dition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of constru on: Dimensions: Depth of solids: Comments(note co i 'on of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Title 5 Inspection Form 6/15/2000 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:0 7 5 � QM=001ift�1lf Owner: PAVJ�a 5' e_i N ,#- cl vvaojt y Date of Inspection: 11146o 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. 3 � i o d 8 Title 5 Inspection Form 6/15/2000 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 00 Owner: 17*yOL Date of Inspection• 4 11 4-1 a sr- SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 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) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain:_ W -{r^GobUt-au9,c wnA-r 1 at Z You must describe how you established the high ground water elevation: Title 5 Inspection Form 6/15/2000 11 PERMIT L°•;0 C A T ION U— -1 , S E W A G E N Q. VILLAGE 1 I I.NSTA LLER'S NAME i ADDRESS B;aU 1 l D E'R OR OWN ER DATE PERMIT ISSUED DAT E COMPLV..ANCE ISSUED Y �•— J 1 -1 x. r � ._.�_� 20 FT MIN: �,. TOP OF OUND. • y 1 y EL. 10 FT. MIN. 'CONCkETE 0 �r� COVERS 4 SCH. 40 PVC CLEAN SAND PIPE- MIN. PITCH 1/8" PER FT. COVERETE 2" LAYER OF 4" CAST IRON PIPE- MIN. PIYC 12 MAX. I' 1/8 - 1/2" WASHED Locus I/4" PER FT d. STONE f . FLOW LINE (7 to EL. ' _ _ <� MIN. ref 9 tg�C r -• : EL - .• N EL EL.= ' 7- EL.= DIST. EL- 9v' LOCATION MAP BOX 3/4"- 1 1/2" e ? a' WASHED STONE o go w cD o PRECAST LEACHING q GAL. - BASIN OR EQUIV. SEPT I C 6.0, LET" ' TANK BOTTOM OF TEST HOLE OR.USGS PROBABLE WATER TABLE EL. = ss, 5 ! PROFILE OF GROUND WATER TABLE( / / ) EL. _ e I r SEWAGE DISPOSAL SYSTEM <sl—ca IOS.SI / 1 ( NOT TO SCALE 1 .� — � DESIGN CALCULATIONS r . SOIL TEST \ \ �0T 3 '� T„aos n JLc NUMBER OF BEDROOMS . 3 9 S ' / j�2 nw DATE OF SOIL TEST r71 ;za V00 s t FG h /� GARBAGE DISPOSAL UNIT. Y F , 60 TOTAL ESTIMATED FLOW WITNESSED BY �• ,/�g'Cr� . l� k ( GAL./BR./DAY x _ BR. e). .. . . .. . 3 37C� GAL./DAY PERCOLATION RATE "2- MIN./INCH REQUIRED SEPTIC TANK CAPACITY..... .. : .:.,: - V '':� -rAL_ _ OBSERVATION HOLE I OBSERVATION HOLE 2 ACTUAL . SIZE OF SEPTIC TANK...,....... ._ GAL ELEVATION ELEVATION = LEACHING AREA REQUIREMENTS -z o SIDEWALL AREA GAL/S.F. BOTTOM AREA / • y GAL./S.F. 9 , o LEACHING 'CAPACITY. •( BOTTOM + SIDEWALL). SS�9 7 GAL. t 1 RESERVE LEACHING CAPACITY..................... GAL. f NOTES ,��� 09ric� �1 t I. ALL WORKMANSHIP AND MATERIALS SHALL 4 CONFORM �•�o\ � .�fN II#'i } o � TO D.E.Q.E. TITLE S AND .THE TOWN OF RULES AND REGULATIONS FOR SUBSURFACE DISPOSAL To�M , wkrErt — OF• SANITARY SEWAGE y 2. ALL COVERS TO SANITARY UNITS SHALL BE BROUGHT TO WITHIN 12" OF FINISHED GRADE. vc�" �� S. EXISTING AND FINAL GRADES SHALL REMAIN ESSENTIALLY MIN. FRONT SETBACK ar rd THE SAME: : MIN. REAR SETBACK '- � 4. NO DETERMINATION HAS BEEN MADE BY THIS OFFICE AS TO 1 ! SETBACK COMPLIANCE WITH TOWN ZONING REGULATIONS..OWNER/APPLICANT IS TO OBTAIN SUCH DETERMINATION FROM APPROPRIATE AUTHORITY. APPROVED : BOARD .. OF HEALTH . - A 41 ' .DATE AGENT GE 110.99 °E�f? PROJECT LOCATION: �6„tm� �il> ,� �. 4£ �i' �'� T t � �/f f��terry ��.-'�•�� � „a. o e- RI CHq►r,D" ` APPLICANT JAAjrS NO 694 EARN . L E G E D ,, _ DR BY- 13aTF: p <. N . 01TARi SCALE� � s'G� • T T VAT 0 EXISTING :SPOT ELEVATIONS , 00 JOB N0 APPD. BY REV.: --- - -- - --, •, ,�, : _ EXISTING CONTOUR 00 � t1tl`.78f� SPOT, A _ f.y FINAL S 0 ELEVATIONS OOA� s<ef..,,t•L . FINAL CONTOUR 00 } aJ�. I , � ;" DRAWING SOIL TES1 LOCATION REG: LAND SuRYEY(7RS-REG SQN/TQR/QNS . _ SITE PLAN NO. 35 'ROUTE ..J 3'4. �=..UN/T .2 SatlT DE7YN/S, AIfASS. .. OF