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0178 BETH LANE - Health
178 Seth Lane Hyannis CP - A = 272 161 . I i 4 i h } S a i 'R 11t 0 No. Fee �- THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ZippYicatiou for Di5po5ar gpp5tem Cou5tructiou Vermit Application for a Permit to Construct( ) Repair pK) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 1`115 Owner's Name,Address,and Tel.No. Assessor's Map/Parcel 7 �� f Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided P gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank _Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title he Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued b t ' oard f He re ne Date Application Appro Date t".'�Application,Disappro e y: Date wfof.the_following reasons or Permit No. Date Issued raww.,..�,rr.�' �^'f.; l`. '. .J. t +t•/�t�i"V .'-"f.r�,'-ram. ar. « ..�- '^"` '. ""tV.,..... n ...3!:'c .... � - -.p._ a - r No. /(/ Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Application for Mioogal *pgtem Cow5truction Permit Application for a Permit to Construct( )) Repair(�4) Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components Location Address or Lot No. 8f ^'� �'- Owner's Name,Address,and Tel.No. I � Assessor's Map/Parcel 9 Installer's Name,Address,and Tel.No. ^Mw� Designer's Name,Address and Tel:No. 7 ,pe of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) o1G e p ck 0 a- p e ti Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title5-of--the'Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this-Board-if Healtl!i. Signe Date i Application Appro d by Date Application Disapproved by: Date for the following reasons A t r Permit No. ^' } Date Issued THE COMMONWEALTH OF MASSACHUSETTS y. BARNSTABLE, MASSACHUSETTS Certiffcate of Compliance THIS IS TO CERTIFY,that the On- Sewage Disposal System Constructed ( ) Repaired ( )c) Upgraded ( ) Abandoned( )by ! `,�,���e; si e _Fdxo to at 17 �t74"�1 Yl �C�1`P has been constructed in accordance with the,provi�sions of Title 5 and the for�D2isposal Sys_tem1Construction Permit No. /t,/A dated Installer �/C��J�.�fi 5 t'c ✓t t9yj N Designer v #bedrooms Approved design flow gpd The issuance of this permit shall not b9 construed as a guarantee that the sy, ern will f ti s esigned. Date 1 c —�[ Insp ctor ———No. /V Fee ✓" THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS Migo!mt *pgtem Congtrurtioti Permit Permission is hereby granted to Construct ( ) Repair ( ) Upgrade ( ) Abandon ( ) System located at (?F;� tZ,rA)y\ r^.A 7 and as describedrm the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction ust be!completed within three years of the date i f this p it. Date O Approved b Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 178BETH LN HYANNIS < I V M Property Address PACHECO Owner Owner's Name information is HYANNIS required for MA 02601 7/24/08 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important:nfilling out When filling A. General Information W forms on the computer,use 1. Inspector: only the tab key to move your DOUGLAS A. BROWN cursor-do not use the return Name of Inspector key. D.A.BROWN a� Company Name � P.O. BOX145 I = Company Address e CENTERVILLE MA Z7;,02632 Ciiy/Town State C' ip Code n f 508-420-4534 S14297 4.r , Telephone Number License Numberrz C'.) N B. Certification 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: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 7/24/08 *nspgnatdre Date pector 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. ****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 V Inspection Forrn.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•page 1 of 15 Commonwealth of Massachusetts Title 5 Official Inspection ection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 178BETH LN HYANNIS Property Address PACHECO Owner Owner's Name information is HYANNIS re uired for MA 02601 7/24/08 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: SYSTEM MEETS MINIMUM PASSING REQUIRMENTS AT THIS TIME,I FOUND NO OBSERVATION PORT ON THE LEACHING SYSTEM. 1 CAN NOT PREDICT FUTURE PERFORMANCE OF THE SYSTEM 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 Title V Inspection Form.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 178BETH LN HYANNIS ` Properly Address PACHECO Owner Owner's Name information is required for req HYANNIS MA' 02601 7/24/08 every page. City/Town State Zip Code Date of Inspection B. Certification cat on (cont. B) System Conditionally Passes (cont.): ❑ 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 pipes)are replaced 1 ❑ obstruction is removed ND Explain: 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. El The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. Title V Inspection Form.doc•11a= Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface System Sewage Disposal S g p y Form Not for Voluntary Assessments 17.8BETH LN HYANNIS Property Address PACHECO Owner Owner's Name information is HYANNIS re uired for MA 02601 7/24/08 every page. City/Town State. Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 indicates absent 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: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® 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: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Title V Inspection Form.doc•08106 Title 5 Official Insp ection Form:Subsurtace Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 178BETH.LN HYANNIS Properly Address PACHECO Owner Owner's Name information is HYANNIS required for MA 02601 7/24/08 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems(cont.): Yes No ❑ ® Any 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 water supply well.with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent 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 and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. E ® 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 necessaryto 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. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate . regional office of the Department. Title V Inspection Formlcloc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15_ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 178BETHIN HYANNIS Property Address PACHECO Owner Owner's Name information is required for HYANNIS MA 02601 7/24/08 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or' Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ' ® ❑ 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) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® Were the septic tank manholes uncovered, opened, and the Interior of the tank inspected for the condition 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: x ® ❑ 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.issde approximation of distance is unacceptable) [310 CMR 15.302(5)] a Title V Inspection Form.doc-08106 Title 5 Official Ins pectionForm:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ye r 178BETH LN HYANNIS Property Address PACHECO Owner Owner's Name information is HYANNIS re uired for MA 02601 7/24/08 every page. Cityrr vn State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required) ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage 06-205/07-143 ( Y 9 (gpd))� Sump pump? ❑ Yes ® No Last date of occupancy: Date Commercial/Industrial Flow Conditions: i, Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): Title V Inspection Form.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 178BETH LN HYANNIS Property Address PACHECO Owner Owner's Name information is HYANNIS required for MA 02601 7/24/08 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed(if known)and source of information: INSTALLED 1995 BY SCOTT FRANK SEPTIC Were sewage odors detected when arriving at the site? ❑ Yes ® No Title V Inspection Form.doc•0806 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 178BETH LN HYANNIS Property Address PACHECO Owner Owner's Name information is HYANNIS required for MA 02601 7/24/08 every page. Cityfrown State . 'Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan):' w Depth below grade: ' feet Material of construction: ❑cast iron ❑ 40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting,evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: feet ~ Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) • x If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No -------------------------------------- ---------------------------------------------------------------------------- ------------------------------- Dimensions: 1000 GALLON 4: Sludge depth: , @12" q Distance from top of sludge to bottom of outlet tee or baffle @24,E .. Scum thickness VARYING BUT THICK Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle z. How were dimensions determined? WODDEN POLE Title V Inspection Form.doc-08106 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 9 of 15 ?,w Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 178BETH.LN HYANNIS Property Address PACHECO Owner Owner's Name information is required for HYANNIS MA 02601 7/24/08 every page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): TANK NEEDS PUMPING, OUTLET TEE WAS MISSING FOR SOME TIME,RECENTLY REPLACED BY ME, TOWN PERMIT WAS PULLED FOR TEE REPAIR. SOLIDS HAD CARRIED OVER INTO D- BOX AND POSSIBLY LEACHING SYSTEM Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ 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: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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): Title V Inspection Form.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•.Page 10 of 15 t Commonwealth of Massachusetts Title 5 Official. Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments .4M 178BETH LN,HYANNIS Property Address PACHECO Owner Owner's Name information is HYANNIS required for MA 02601 7/24/08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes . ❑ No Alarm level: Alarm in.working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan):. . o„ 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.): DEFINATE SOLID CARRY OVER, BUT LIQUID NOT ABOVE OUTLET INVERT Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Title V Inspection Form.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 178BETH LN HYANNIS Property Address PACHECO Owner Owner's Name information is HYANNIS required for MA 02601 7/24/08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: COULD NOT FIND OBSERVATION PORT AS PER AS BUILT Type: ® leaching pits number: 1 ® leaching chambers number: 4 INFILTRATORS ❑ 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.): NO SIGNS OF HYDRAULIC FAILURE FROM THE SOIL CONDITIONS. BUT AS PREVIOUSLY STATED NO OBSERVATION PORT WAS FOUND SO WE WERE UNABLE TO OPEN THE LEACHING SYSTEM Title V Inspection Form.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 178BETH LN.HYANNIS Property Address PACHECO Owner Owner's Name information is HYANNIS required for MA 02601 7/24/08 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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 scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(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.): Title V Inspection Form.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page.13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 178 BETH LN Property Address PACHECO Owner Owner's Name information is HYANNIS re uired for MA 02601 7/22/08 every page. City/To vn State Zip Code Date of Inspection D. System Information (cont.) 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. n I ' 2.Q k 2,0 5 - `13 3 31 4- 94 5 zS • r. Tide V Inspection Form.doc•08106 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 178BETH LN HYANNIS Property Address PACHECO Owner Owner's Name information is required for HYANNIS MA 02601 7/24/08 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Ex am: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to ground water: 6FT feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ 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: You must describe how you established the high ground water elevation: OFF AS BUILT CARD FROM SCOTT FRANK SEPTIC Title V Inspection Form.doc•08M Title 5 Official Insp ection Form:Subsurface Sewage Disposal System•Page 15 of 15 1Hf Town of Barnstable �p Tp� Regulatory Services BARNSfABLE,,* Thomas F. Geiler,Director . 9$ tb SS, �0� �TF139. a Public Health Division Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 REGARDING SEPTIC INSPECTIONS BY PRIVATE CONTRACTORS DISCLAIMER This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original or copy of the report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observations and interpretations contained within this report. In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would be listed on the "Disposal Works Construction.Permit". If you should have any questions regarding this report, please contact the certified Septic System Inspector who conducted the inspection. QASEPTIMisclaimer Private Septic inspections.DOC' t �. ZC)4 I COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE,OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION 5 TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 178 Beth Lane Hyannis Owner's Name: Christine Bosworth Owner's Address: f Date of Inspection: 4/27/2005 N cu Name of Inspector: (please print) Patrick T. Sullivan Company Name: Ready Rooter Mailing Address: P.O.Box 371 Sandwich,MA 02563"', co Telephone Number' (508)888-6055 c:) r 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: Conditionally Passes Needs Further Evaluation by the Local Authority Fails' Signature:. Inspector's Si p g Date: 0 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 ( n -:_Q` V�G C'c�a c--• �"�,'! �t'r�'�Z'e� G�`dG G ****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. Page 2 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART A CERTIFICATION (continued) Property Address: 178 Beth Lane + '' Hyannis Owner: Christine Bosworth Date of Inspection: 4/27/2005 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D C. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: y 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. J 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 breakout 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 of obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed IA explain: VIP,4L.J p. Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM,INSPECTION FORM PART A CERTIFICATION(continued) . Property Address: 178 Beth Lane Hyannis Owner: Christine Bosworth Date of Inspection: 4/27/2005 C. Further Evaluation is Required by the Board of Health; Conditions exist which require further evaluation b the oard'of Health in order to qY 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 whic(will protect public health,safety and the environment: Cesspool or privy is within 50 feet a surface water Cesspool or privy is within 50 fee of a bordering vegetated wetland or a salt marsh '2. System will fall unless the Board of Health('and Public Water Strlier,if any)determines that the system is functioning in a manner that protects the publiclealth,sa sty and environment: _The system has a septic tank and soil absorption system(S S)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 i within a Zone 1 of a public water supply. s r . _The system has a septic tank and SAS and the S is within 50 feet of a private water supply well. r P _The system has a septic tank and SAS and ih' SAS is" e less than 100 feet but 50 feet or more from a private water supply well". Method used to d r'mine.distance "This system passes if the well water anal y is,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds Indic es that. he well is free from pollution from that facility and the presence of ammonia nitrogen and nitrat itrogen is equal to or less than 5.ppm,provided that no other failure criteria are triggered..A copy of the alysis must be,attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 178 Beth Lane Hyannis Owner: Christine Bosworth Date of Inspection: 4/27/2005 D. System Failure Criteria applicable to all systems You must indicate"yes"or"no"to each of the following for'In inspections: ' Yes No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to th1.e surface of the ground or surface waters due to an overloaded or .clogged SAS or cesspool 4 Static liquid level in the distribution box above outlet invert due to and 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 _ Z Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. __Z Any portion of a cesspool or privy is within,a Zone I-of a public well. z Any portion of a cesspool or privy is 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 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 of the above 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 'Iith a_ design flow of 10,000 gpd to 15,000 gpd _. You must indicate either"yes or"no"to each of the followin (The following criteria apply to large systems in addition to a criteria above) yes no the s stem`is within 400 feet of a surface dr' ' — — Y mg M 'water.suP. ,,. r , P X the system is within 200 feet of a tribut to a surface drinking.water supply the system is located-in a nitrogen nsitive.area(Interim Wellhead,Protection Area—IWPA)or a mapped Zone II of a-public water supply ell If you.have answered"yes"to any que ion in Section E�the system is considered a significant threat,or answered "yes in Section D above the large stem has failed.The owner or operator of any large system considered a significant threat:under Section Elr failed under Section D shall upgrade the system in accordance with 310 CMR . 15.304.The system owner.sho d contact the appropriate regional office of the-Department. Page 5 of 11 OFFICIAL INSPECTION FORM,-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 178 Beth Lane Hyannis Owner: Christine Bosworth Date of Inspection: 4/27/2005 ' Check if the following have been done. You must indicate"yes' or"no"as to each of the following: 1= , Yes No Pumping information was provided by�the'owner,occupant',or Board of Health Were any of the system components pumped out in tlie�previous two weeks? 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) Was the facility or dwelling inspected for signs.of sewage back up? Was the site inspected for signs of break out?' Were all system components,excluding the SAS, located on site?` Were the septic tank manholes uncovered;opened,and the interior of the tank inspected for the condition 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 than 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: w s Yes No Existing information. For example,'a plan at the Board of Health. s l 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)] Page 6 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM r; PART C SYSTEM INFORMATION Property Address: 178 Beth Lane Hyannis Owner: Christine Bosworth w Date of Inspection: 4/27/2005 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): 3 �; Number of current residents:-- Does residence have a garbage grinder(yes or no): "t Is laundry on a separate sewage system(yes or no):,, yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no):,--0c0 Water meter readings, if available(last 2 years usage(gpd)): Sump Pump(yes or no):,,,�---) F Last date of occupancy: L-2 r COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd . Basis of design flow(seats/persons/sq.ft. etc - Grease trap present(yes or no): Industrial waste holding.tank present s or no):— Non-sanity waste dischar ed tot Title 5.ry g stem s es y (y or no): Water meter readings, if availab Last date of occupancy/use: y, OTHER(describe): 7 . GENERAL'INFORMATION Pumping Records Source of information;. Q �Was system pumped as part of the inspection(yes or no): C 5 "� If yes,volume pumped: t© c7gallons--How was,quantity pumped determined? Reason for pumping: TYPY OF SYSTEM Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy Y )(' . _Shared system.(yes or no if yes,attach previous inspection records;if any) ' Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system,owner),, ; Tight tank _Attach a copy of the DEP.approval , Other(describe): Approximate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site�es or no):.A2:!:-> Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM,INSPECTIONFORM PART C SYSTEM'INFORMATION (continued) Property Address: 178 Beth Lane Hyannis . Owner: Christine Bosworth Date of Inspection: 4/27/2005 BUILDING SEWER(locate on site plan) Depth below grade: j ' u Materials of construction:_cast iron Z40 PVC other(explain): Distance from,private water supply well or suction liner 1_/ ' Comments(on condition of joints,venting,evidence of leakage,'etc): SEPTIC TANK: locate on sit e e plan .. , Depth below grade: ' Material of construction; ncrete_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: LJ Sludge depth: �" k Distance from o thelo [ <of sludge e to - bottom of outlet tee or baffle:b p g. Scum thickness: Distance from top of scum to top of outlet tee of.baffle:- Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined:. Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence,of leakage,etc:): "s4 `Fz, �,.. ter• G3Lrs�.say�`�/.r... GREASE TRAP:_(locate on site plan) Depth below grade: Material of construction;•'_concrete metal /� s-s •_polyethylene_other(explain): - - Dimensions: Scum.thickness: Distance from top of scum to top of outlet tee r baffle: Distance from bottom of scum to bottom of tlet tee or baffle: Date of last pumping: *' Comments(on pumping recommendatio s, inlet and outlet tee of baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of eakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM ,NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEM INFORMATION(continued) Property Address: 178 Beth Lane Hyannis Owner: Christine Bosworth Date of Inspection: 4/27/2005 TIGHT or HOLDING TANK: (tank must be pumped at e of inspection)(locate on site plan) Depth below grade: Material of construction:_concrete_metal_fibe ass_polyethylene`_other(explain): Dimensions: Capacity: gallons Design Flow: gallons/da Alar m es r p ent(yes or no): . . Alarm level: Alarm in workin order(yes or no): Date of last pumping: Comments(condition of alarm and oat switches,etc.):' DISTRIBUTION BOX: present must be opened)(locate on site plan) Depth of liquid level above outlet invert: ©` Comments(not 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:_ (locate on site pl Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump amber,condition of pumps and appurtenances,etc.): Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART C. SYSTEM INFORMATION(continued). Property Address: 178 Beth Lane . Hyannis Owner: Christine Bosworth Date of Inspection: 4/27/2005 SOIL ABSORPTION SYSTEM(SAS):_(locate on site plan,excavation not required) If SAS not located explain why: Type _eaching pits,number: leaching n g chamb ers, s,nu mber: _leaching galleries,number: leaching trenches, number, length: leaching fields,number,dimensions: overflow cesspool, number: a . 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.): va,rn<�ve�C, CESSPOOLS: (cesspool must be pumped as p of inspection)(locate on site plan) Number and configuration: F Depth—top of liquid to inlet invert: % Depth of solids layer: Depth of scum layer:' Dimensions of cesspool: Materials of construction: Indication of groundwater infl- (yes or no): 4 Comments(note condition gf soil,signs of hydraulic failure,,level of ponding;condition of vegetation,etc.): PRIVY:. (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): Page 10 of 11 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 178 Beth Lane Hyannis Owner: Christine Bosworth Date of Inspection: 4/27/2005 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. . - .. O Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION'(continued) Property Address: 178 Beth Lane Hyannis Owner: Christine Bosworth Date of Inspection: 4/27/2005 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 groundwater 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 the local Board of Health-explain: Checked with local excavators, installers-(attach documentation) :ZAccessed USGS"database-explain: v.n.4,w�• �;s� ��.:. You must describe how You established the high_ground water elevation:' - J'JcD L `i`,c�.J�- . -' SAG�,�-'-'�:_S L cK: ,�7 S� �J C__.�e�� 6`�2'_ '4t �.�-t`_�c:,.[a\ lam`•y��.J -- ... .. a-.. ,. _ �S 1,0\ COMMONWEALTH OF M4SSACHUSETT CT F� w EXECUTIVE OFFICE OF RN-VIR0NMENT.��L'AFF'�,�e�3 19. DEPARTMENT OF ENVIRONMENTAL PROTEeff'O-S � ONE WINTER STREET. BOSTON. MA 031@5 Fi _S:•��:( 11". VFILLIAN:F K•ELD TRUDY COX Governc• Se:resa ARGEO PAUL CELLUCC1 DAVID B STRUY. Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM , Commission PART A CERTIFICATION Property Address: \1 9-- %--T\rn Lv-z Address of Owner: Date of Inspection: ttAl Of different) Name of Inspector: 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: / a n a'019r.1 0% N.t ak 4�-_/ Mailing Address: Rep pox e_375?C£ 2C4.c/ Telephone Number: rye t;- /L/ = CERTIFICATION STATEMENT I cer.ihl that I have personal!,, inspected the sewage disposal system at this address and tha: the information reported below is true. accurate and complete as of the time of mspec;,o-. The inspection was performed basec on m} training and experience in the proper funmor, and maintenance or on-site sewage disposa• systems The systern: Passes Conc-nonaiiv Passes Neec; Funhe• E.•a!uat:oh 9\ the Local Apprpvrng Autnonr\, Fa Inspector's Signature: Date: The Sys;e^ Insoec-to, sha" submit a cop\, of this inspection report to the Approving Authonn within them I30, days of completing this inspection. It the syster' is a sharec system o- has a design flow of 10.000 god or greater, the inspector and the system owner shall submit the repo-: to the a=roor:a;e reg:or.al office of the Department o` Environmental Protec::on •Tne orig:na! should be sent to the systern ow•ne- and copies sent to the buve% if applicable. and the approving authorm INSPECTION SUMMARY: Check A, B, C, or D: AI SYSTEM PASSES: I have not found any information which indicates that.the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: BI SYSTEM CONDITIONALLY PASSES: One or more system components as described in the 'Conditional Pass' se-non need to be replaced or repaired. The system, upor completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes, no. or not determined (Y, N, or NO:. Describe basis of determination in all instances. If'not determined`, explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within rwenry (20) years prior to the date of the inspection; o the septic tank, whether or not metal, is cracked, structurally unsound. shows substantial infiltration or exfiltratron, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. lrrav:and 04 25 1 .' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECT10% FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: BJ SYSTEM CONDITIONALLY PASSES leontinied _ Sewage backup or breakout or high static water level observed in the distrib box is due to broken or obstructed pipe(sl or due to a broken, settled or uneven distribution box. The system "11 pass inspection if(with approval of-the Board of Health;. Describe observations: broken pipes', are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to roken or obsaructed pipe(sl. The system will pass inspection if twith approval of the Board of Health): broken pgwsi are replaces obstruction is removed Cj FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH Conditions exist which require further evaluation by the Boar of Health in order to deuermine if the system is failing to protect the public health, safest•and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETE INES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 5 ETY AND THE ENVIRONMENT: Cesspool or pri.-, is within 50 feet of a surfa a water Cesspool or pn., is within 50 feet of a boy eying vegetated wetland or a salt marsh. 2) SYSTE.Vt WILL FAIL UNLESS THE BOARD OF H LTH (AND PUBLIC WATER SUPPLER,IF APPROPRIATE) DETERMINES THA THE SYSTEM 15 FUNCTIO%ItiG IN A MANNE THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system+ has a septic tank and it absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributam, to a surface water supp .•. The system has a septic tank a soil absorption system and the SAS is within a Zone I of a public water supa'y well. The systern has a septic tank c soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tan and soil absorption system and the SAS is less tfxar. 100 feet but 50 feet or more from a private water supply well, niess a well water analysis for cohform bacteria and volatile organic compounds 'indi=es tlt< the well is free from poll ion from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Meth used to determine distance (approximation not valid). 3) OTHER lz.vaa.L 04;25/!'x Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORtit PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: DJ SYSTEM FAILS: You must indicate either "Yes" or "No' as to each of the following have determined that the system violates one or more of the following failure criteria defined in 310 CMR 15.303 The bans for this determination is identified below. The Board of Health should be contacted t determine what will be necessary to correct the failure. Yes No Backyp of sewage into facility or system component due to an overload or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surfac waters due to an overloaded or clogged SAS or cesspool. S;a:ic hco;,d level in the distribinon box above outlet invert due to an overloaded or cloggea SAS or cesspool Licuid depth it cesspoo! is less than 6" below invert or available volume is less than 1/2 day flov. Reou,re= pumping more than, 4 times in the last year NOT du to clogged or obstruct ea pipe s Numoer o�times pumped _. Any por,:on o'the So!! Absorption System• cesspool or pri is btlow•the high groundwate• elevation An,. per:.or• o'a cesspool,or priv1 is .%;thin 100 feet of a urace water suppiv or tributan to a surface Kate, supply. And po-:ion of a cesspoo' or prn is w ilhir a Zone I o'a public well. Am pe-�.c-. c,a cesspoo' o, pr;-.-; is 50 feet a private water supph wel! Am por.o-.•o-a ce<s000l or pri\•,• is less than 100 eet but greater than 50 fee; from a private water supoi%, well with no acceo;abie wa:e• quaht.. analvs s If the w•e!I has en analyzed to be acceptable. artach,cop% of well water analvsis for coliiorr,. ba,,er,a \,o!a:Je organic compounds, a monia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: 1 ou must indicate either "Yes• or "No- as to each of the follow ng. The fo!iow:ng trite,-a app,,. to large systems in addr, n to the criteria above: The system serves a facilin with a,design fiow of 0,000 gpd or greater (Large System; and the s%,stem is a significant threat to public hea!th and safes and the environment be use one or more of the following conditions exist: Yes No the system is within 400 feet of a s rface drinking water supply the System is within 200 feet of tributary to a surface drinking water supply the system is located in a nitr en sensitive area (Interim Wellhead Protection Area • IWPA) or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CN1R 5.00 and 6.00. Ple se consult the local regional office of the Department for further information. (revised 04/35/97) Page 3 o1 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property.Ad-dress: �'1�l V1K(,,tom Owner. 4�1R Wo Date of Inspection: (011btI Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes N0 Pumping information was provided by the owner, occupant, or Board of Health. _ hone of the system components have been pumped for at least two weeks and the system has been rece+v:ng normal flow rates during that period. large volumes of water have not been introduced into the system recently or as pan of this inspection _ As bull: plans have been oma:ned and examined. Note if they are not available with NIA The iac:lin. or d�+elhng N%as inspected fo, signs o-sewage back-up _ The systern does not receive non-sanitary or industrial waste flow. The site ,-.as inspected for signs of breakou: All s\ste+r components. excludir.e the Sol!. ADsorption System, have been located on the site. ` _ The sepc.c tank manh6e> were unccvered. opened. and the interior of the septic tank was inspected for cond-tion of barfies or tees. mater;ai o' cons-,ruction. dimensions, deptn of liquid, depth of sludge, depth of scum. The size and loca:,on o'the Sol' ?.bsorauon Svstern On the site has been determined based on The iac.l.n o\%nee ,ano occuoants. rf d.fte•en: trom owner were provided with information on the prope• maintenance of Sub-Surface Disposal Svsterr. _ Existing information Ex Plan a: B O H X _ Determined in the field :r.'an% of the failure criteria related to Part C is at issue, approximation of distance is unacceo:ab-e (15.302 31'b? (revised 04/25/5?i Page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: \-I%%j1TrN Owner: SNc,�IJ Date of Inspection: 1 FLOW CONDITIONS RESIDENTIAL: Design floe. .D.dlbedroom for S._A.S Number of becrooms 6 3 Number o:current residents Garbage g,• der (yes or nog, Laundry cc-•^ected to system (,yes or no' 4e. Seasonal use Ives or no Alp Water meter readings, if available (last two .2 year usage tgod): Uo Sump Pump Ives or note Las dare o- occupanc- CONIMERCIAL11NDUSTRIAL• Type of establishment. Design fto%% _Rahons;ca% Grease trap present tees or no_ Industrna! %%aste Holding Tank oreseri; -%-es or no_ 'ion-san:ta-� t^zste d-scnarged to the T:;ie 5 s\•stem ;yes or no_ %%ater meter readings if availabie Las:Fa:e o, c ;znc. t OTHER: .De_cnbe Last cafe or. occudanc. GENERAL INFORMATION PUMPING RECORDS and sourcqe of infor: tfon 4. System pumped as par, of inspection. tves,or no. 1-1- If ves, vo:ume pumped gallons Reason for pumping TYPE OF SYSTEM !S( — Septic tank,/distribution boxrsofl absorption system Srngie cesspool CNerflow cesspool Prn-), Shared system (yes or no! (if yes, attach previous inspection records, if any) VA Technology etc. Copy of up to date contract? Other APPR XIMATE AGE of.all components, date installed (if known) and source of information: t �Q'jQ� 6 y zN�t 1Tv�sro� Sewage odors detected when arriving at the site. (yes or no) 00 (zwioed 04/25/91; Page 5 of 10 SLBSURFACE SE)rVAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYS—E.M INFORMATION (continued) Property Address: %—tcb b-a.'tr , Owner: aQ N Date of Inspection: �0 �1G I'q7 BUILDING SEWER: (locate on site plan) Depth below grade. Material of construction. _cast iron _40 PVC _other (explain` Distance from private water supply well or suction Ire Diameter Comments: (condition of joints• venting, evidence of leakage. etc.) SEPTIC TANK: (locate on s!te p an Depth below grade 6�� Material i onstruetio.n. concrete me:a Fioergiass _Polyethylene _othertexplam o c � _ _ if tank is metal. Iis: age _ IS age cor.i.rmec b� Ce-;:fica:e o: Compuance _(NesNo Dimenslor.s �b�C�la'� Sludge depth 1Z° q Disiance irom top o: siuoge to bono-: of out;e: tee o• ta-'e Z Scum thickness 3'� Distance from top of scum to top o�outle: tee or bake lorj M Distance irom bottom o; scu-n to bo-. c*.n o'out( : tee e• baT.e _L� Howdimensions Here dete•minec A( Comments (recommendation for pumping rondition o; inlet an' outle! tees or baffles. depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage. etc wvl r e u T p'► GREASE TRAP:_ (locate on site plan. Depth below grade. Material of construction. _concrete _metal F berglass _Polyethylene —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: (recommendation for pumping, condition of islet .and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural tn,egrrt)•, evidence of leakage, a:c ; (re,%sed 04125:37) Page 6 of 10 V SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORm PART C SYSTEM INFORMATION (continued) Property Ad dress:�1?/ 9 Wh Owner: MI SC-p Date of Inspection: I6[IL1y7 SOIL ABSORPTION SYSTEM (SAS): (locate on stte.plan, if possible, excal tlon not required. but may be approximated by non-intrusive methods, If not determined to be present, explain: Type: leaching pus. number. leaching chambers, number.-'t If4w1 tMtTCft.S leaching galleries, number. leaching trenches, number,length. leaching fieids, number, di^nens.o^s ove+=loµ• cesspool, number Alternative s%,stem Name of Tecnnoiog% Comments. to r? condition of soli, s!gr,.s of hydrailic failure, lever of pondin . condition of vggetat� n, a .I O O V CESSPOOLS: (locate on site plan numbe, and cor:f,g,;ra:,on Depth-top of liquid to inlet Inver; Depth of solids lave- Depth of scum layer Dimensions of cesspool Materials of construaior : Indication of groundhate- inflow tcesspool must oe pumper as par, of m5peRion. Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: v (locate on site plan) Materials of construction: Dimensions. Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of pondmg, condition of vegetation, etc.) lswasad 04/25/9^) Page / of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR.tit PART C SYSTEM INFORMATION (continued) Propem Address: WD\ O%ner: �'14NC�r1 Date of Inspection: 01(J 47 TIGHT OR HOLDING TANK: IJu .?ank must be pumped prior to, or at time, of inspection: (locate on site plan. Depth below grade Material of construction. _concrete —metal _Fiberglass _Polyethylene _other(explain) Dimensions. Capac,n gallons Deng floM gal;onida. Alarm level A:a•m in %%orking order _ Yes. _ No Date of previous pumping Comments (condition of inlet tee. condition: o- a'a•m. and float switches. etc.) DISTRIBUTION BOX: docz-e on site p a- Deg:^ o' hcu+d lee' aoo•.e o:,tie: rn�e' u _ (�2(�Dytow.a =%A p'� Cornrne-.ts mote r leve' and d:st•ib-,ro^ is e , ,c.ence oT solids carn,over, evi nce of leaka�,,e into or out of box, etc.) �-@pax .6 l o u's T1�btJ'R�t�► ��I !4S �k%A 2968:6.64 o tXILL kJQ R 141 Q1.e1�lCr�, PUMP CHAMBER:KIN (locate on site plan. Pumps in working order: (Yes or No, Alarms in working order (Yes or No Comments. (note condition of pump chamber, condition of pumpi and appurtenances, etc.) (r.v%sed 04/25/97) rag. 7 of 10 l I f } SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM I%FORMATION (continued) Propert, Address: J19 t Owner: QklQsJ Date of Inspection: 6b�l4y7 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100 (Locate where public water supply comes into house) Q.�ca►� A - 3 y s Q A'z �.�' Q�2-;Ly� RS a 85� 43 (revla•: 04'25!57; Day 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: 44044 Date of Inspection: t ID (b197 I Depth to Groundwater Fee: Please indicate all the methods used to determine liigh Croundwater Elevation: A&%b"" ' CA VA Obtained from Besrgn-Pans on record Observation o`. Site (Abutting properry. obsen•ation hole, basement sump etc.) Determine it from local conditions Cnec� \+ith Iota' Eaard o• nea::r Chec'k FEti1A Milos Check pumping records Check Iotal eacavato-s rrstalle•s Lse LSCS Da:a r• Desc-ibe in von' o+ +••o,c- ro-•+ +o_ es:ar;;6-.ec the GroundAater Elevation. (Must be completed �tb bv.C� cAta en am'S IJo wo. -� (�I �1�� low. o-� JTo+v-e, r•.� �►��1ZQ.rtito�S , lzwcied 24.'2519-. Page 10 of 10 TOWN OF BARNSTABLE 'LOCATION '*T'ti? (2- Z1 ,_ 1.._.®, SEWAGE # S' !s'75- ,tViI,LAGE ASSESSOR'S MAP & LOT�1 b s TSTALLER'S NAME&PHONE NO. '•: SEPTIC TANK CAPACITY L� 7; LEACHING FACILITY: (type)IV= (size) nc<>-JkA NO.OF BEDROOMS BL�'Ii.DER OR OWNER PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 6 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 y,> �i .rn` '•r � �c— Sys ;o..� ells?lam O x- ➢' O O VO U3 U* p V a - � Ll "' TOWN OF BARNSTABLE LOCATION `� � Ecy,4 SEWAGE # VILLAGE C ASSESSOR'S MAP & LOTZ' `INSTALLER'S NAME & PHONE NO. ,SC6 SEPTIC TANK CAPACITY ,,(jou (. -at, (30x fi 0 �h¢' 0 LEACHING FACILITY:(type) . f�t`��Z9fs` (size)(,t) s NO. OF BEDROOMS PRIVATE WELL O UBL /WATER BUILDER OR OWNER E(nr J C-}��/�• S� DATE PERMIT ISSUED: Cg DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No X GZ o O W� No.--._..�-...... � a ! °' Fps... . .o 6 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Allp iration for Diipu3al Wi nrk,i C oustrn tinn ramit Application is he made fo P mit to Construct or Repair V an Individual PP Y ( ) p ( ) al Sewage Disposal P Syst at: _. C..3�.... .__� .. e .. � ........ ----1•-7.1............................................... ���� �����('''(� ( ddr^ss.... ... . •........................... or Lot dreNo. c -le ........ ---------------- Installer .....w.......... Address Q Type of Building Size Lot................ ------.-Sq. fat Dwelling— No. of Bedrooms------------3---------------------.-----Expansion Attic ( ) Garbage Grinder aOther—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Q Other fixtures ------------------------------------------------------ Design Flow.............................:.............gallons per person per day. Total daily flow.._....----_---_-..._---.............,......gallons. WSeptic Tank—Liquid capacity.(M_()gallons Length---------------- Width---------------- Diameter................ Depth................ x Disposal Trench—No. .................... Width-------------------- Total Length-------------------- Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) a Percolation Test Results Performed by-------------------------------------------------------------------------- Date.................................. ...... Test Pit No. I----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water_--__-.-.-_.-._-----.. 44 Test Pit No. 2................minutes per inch Depth of Test Pit_--.---_______-__ Depth to ground water------------------------ R: .................... Descri tion of Soil_._..' `!.---__-_- P U .............................................. -•---••-•••------•-•-•-•--Y...........................................................................................................................w x = U Nature f Re airs or terati ns—Answer when applicable... _ ..__ . ...... ........ • ----••••••.. . .--•••- •----•-•-- �----------- ---------------------------------------•-------._:. .._.... Agreement: 4�n � lJ� v r-f CS ' C y ^G � ��V�� The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of`TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compli ce has been is e board of health. y�Q� Signed ----- `' —'" --------------- ---------------------- ----- Application,Approved BY ------------------ -.W_ _ --- ---------------------------------._--------------------- ----� . . Dace Application.Disapproved for the following reasons: ---------------------_.------....._-----------------------------.._......--------......--------------------------------------- ... ... ------ ----------- --------------------------------------------------------------- � -- e Permit No. 9� /j�2�.... Issued --------� f ...- Dace -"`-FH`E COMMONWEALTH. OF MASSACHUSETTS . BOARD OF HEALTH - - - - R TOWN OF BARNSTABLE Applirdtion for Dis i!mj Mork,a Tomit7), an rrmtt Application is by made fog P mit to Construct or Repair an Indi i System at: �� ( ) P ( v duah Sewage Disposal ! ovation-: ddress or Lot No. - t ..._� s -- ----------------------------------- ---- Nk Owncr -^_......-r-_.... r A dress Installer Address U Type of Building Size Lot ------•-----...........SQ. feet .4 Dwelling— No. of Bedrooms------------ __________________________Expansion Attic ( ) Garbage Grinder l ' aOther—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) d Other fixtures ..........-...... W Design Flow..........:.................................gallons per person per day. ,Total daily flow..------------------------------------.......gallons. WSeptic Tank—Liquid capacity_(00_0gallons Length_____...__.____ Width---------------. Diameter_............. Depth................ xDisposal Trench—No. .................... Width-------------------- Total Length-------------------- Total leaching area----_...............sq. ft. ..;Seepage Pit No--------------------- Diameter____________________ Depth below inlet___-__---__---__.-__ Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) �" Percolation Test Results Performed by............................................ Date........................................ ' - Test Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water-.___.__________-.---._. fs. Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ ----------•---------------------------- ---•------ D Description of Soil..... � __...__� c� ......(.:�_��S! W - ------------------------------------------------------------------••••--------- U ........................................................................ 0 Nature 9f Repairs or terati ns—Answer when applic __.. - ..,_ __._ _ .. _ --- -- ----- ---- --- •----------•-!-•., --- � .... Agreement: L, .� � �rf��5 `l P4 SA10 cv"(��/�J The undersigned agrees to install the aforedescribed Individual Sewage Disposal-System in accordance with the provisions of,TITLE 5.:_,of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has beenji5,wed_by the board of,health. Signed ...... --------------------------------- - ---.----------------------------------------- ------- -----((r,.-/�----------- Application,Approved BY - - ------- ----------- _--- ------- ... � Dare Application.Disapproved for the following rearon.r- -------------------- -...-. -:...... - .... ............. ........................................r--------------------------------------------------- ----------------------- -------------------------- ------ . Permit No. 9 I-���.... Issued - d? e--------------------------------------- y{ Dace d:—u——o o+s—<. —mo.—a�>..<>��s.=. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE CITEr#ifirate of Tolmplian le r / THIS IS TO C RTIFY That the In ividual Sewage Disposal.System constructed ( ) or Repaired (�! ) by ...... 5? ---------- ,,J� __ ------------- --------------------....-----...-------.....-----------------------------.------------- In„WIer atUr--- �. C-�.. fsU�/\ ....... ----------------------------------------------------------------------------------------------------- has been installed in accordance with the provions of TITLE 5 of Thew E vironmental Code s des ribed in the application for Disposal Works Construction Permit No. .� /_.__ _- -.-.- dated ....��„ S'...t_.._- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.,- ......... --------- Inspect r -. -° .� s THE, COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE a No......................:.. FEE........................ Rupn,ial Workii Tiun.Wndi.un lerutit Permission is hereby granted----- C �C� ".---- �---------------------------------------- ----• .. to Construct ( ) or Repair (�an Individual Sewage Disposal System at No.....................�. �� f ................1 1 ------•-•-------------- � t, - - Streey as shown on the application for Disposal Works Construction Permit No._.5 -_�� ated... . �_ �-SI Zlnf""' Board�Health DATE------------• _,�"/�._----- ............................................... FORM 36508 HOBBS R WARREN.INC..PUBLISHERS CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) hereby certify that the application for disposal works ' construction permit signed by me dated Ic ��s , concerning the property located at 2E 20 's �o meets all of the following criteria: • There are no wetlands within 300 feet of the proposed septic system There are no private wells within 150 feet of the proposed septic system • The observed groundwater table is 14 feet or greater below the bottom of the leaching facility • There is no increase in flow and/or change in use proposed • There are no variances.requested or needed. SIGNED : .: DATE: �J LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system. Also if the licensed installer pcsesses a certified plot plan, this plan should be submitted]. LOCATION SEWAGE PERMIT NO. I jl� e el 42S-� A,-e VILLOGE N_STA LLER'S NkME 8 ADDRESS /Y 6 . 4 6 /to w BUILDER OR WNER DATE PERMIT ISSUED �2 _ DATE COMPLIANCE ISSUED -72 I v` i 6� �,'I o �o 'C ��• I 0 � � -1Q W m e. l J + ,2�..... Fss..... Z 5............ THE COMMONWEALTH OF MASSACHUSETTS ko� BOAR® Off` HEALTH ............ ........OF..........; ---------------------------------------------- Appliration for Bhgp iial Works Tomitrurtium Vamit Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal System at: .......� Tf ......... y��.Nr.,�'---------- .......... ................................................................ dare ......._ 8_dXt-' ..-f ..............-- ....................... ne A(� Installer Address Q Type of Building Size Lot_._ AV.......Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) '4 Other—T e of Building ............... No. of persons......_...._._...__.._____.. Showers — Cafeteria p-' Other fixtures W Design Flow................ ............................ per person per day. Total daily flow................ ........_......gallons WSeptic Tank—Liquid capacity.JPooq.gallons Length_9.6 ..... Width.41.-I®... Diameter---------------- Depth..S...Y._-. xDisposal Trench—No. .................... Width.................... Total Length..................... Total leaching area.....................sq. ft. Seepage Pit No.-•-•---1_-._--____-- Diameter... .._. Depth below inlet-----j(�t. ........ Total leaching area..;?:U_....sq. ft. Z Other Distribution box (`-*r Dosin tank ( ) i Percolation Test Results Performed by.._�-, ..................................... Date..` 'Oe-,_ a ---- •------- - ..... •...... Test Pit No. 1... 2----minutes per inch Depth of Test Pit____1_1-:...... Depth to ground water----- .,. GT4 Test Pit No. 2___.:!�2....minutes per inch Depth of Test Pit----- _ -_....... Depth to ground water-----� _ •------•--------------------•-•-----------•---•----•----• .............................................................................. O Description of Soil..__. t .."'.....�. ... x w ------•-•-------------------------••.... ......--•••-•-•-------•........ UNature of Repairs or Alterations—Answer when applicable................................................................................................ Agreement: _ " ' } The undersigned agrees toy install the aforedescribed Individual Sewage Disposal System•in"accordance with the provisions of'ITL%, 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been isWjedd by the board o e th. lid Sign Date Application Approved By ,� ,-t ....... ..................... ••--•--• ,/t� - � Application Disapproved for the following reasons--------------------•---•-•-••-----•--------••-••----•-----••--••----•-----•-•---•-•--••--•-•-••-•............. ...._•-•-••••----•-•--•••••-•------•--....._..••-•...•-•-•-•..........-•---------...•...----•-•.............•----••---------•------•------•-------•---------------•------•----•------ Date PermitNo......................................................... Issued...... ...... 1` Date No.. T .. ..... ..5. ............ Fss. ' THE CQMMONWEALTH OF MASSACHUSETTS BOARD Z HEALTH............V. ........OFis Aptiration for Uiupuual Works Towitrurtion thrmit Application is hereby made for a Permit to Construct or Repair ( ; ) `an Individual Sewage Disposal System at• / ......1.. ......: ..� . A..� �s ----- --------�lo .......................................................... 61z 1P�C-.. °`./Y...... tF, �s.---.--.---�QX ....°r O n Add es a . ......Dl !!/. e �r9 S?. ''_4...... , *�...... /�!/1 �PYl � . Installer Address S Type of Building Size Lot ..�00_....... q. feet rU Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers — Cafeteria a' Other fixtures ........................... W Design Flow........................................••..gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results . Performed by..................................•-..................................... Date........................................ a Test Pit No. I................minutes per inch Depth of Test Pit....._..........._.. Depth to ground water____-__--._-_-__-____--. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a' ................. ----------------------•-----------------•------.........................--------...------....-•-----------•--...---.........------••. ODescription of Soil....................................................................................................•••-------•••-••-•------...-•-•••••••-•--••-•......•--.........---- U •--•--•----------------•-----------------••----......--•-------------------------•--••-----• ... W ........----Y........................................................................................................................................................................................... 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 i}T"T E 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation,until a (certificate of Compliance has been tied by the board of W � Si -- ----- ------- nazg - Application Approved BY v ..: -------------------• Date Application Disapproved for the following reasons:---•-----------•---•-------•----•--•--•-•-•---•--••.----------••---------•--•--•-----------•---•------•--------- --------•-----•.............•----•-------------------•-•-......--••------...--••--•-•--•--••----------•----••••--••••--•-•••-••--•----•--•---•••-••••--••-•---•-•-•......---------• ---••-••-•--•. Date PermitNo......................................................... Issued----------•-------------------•.------••--•-•......•-- Date THE COMMONWEALTH OF MASSACHUSETTS ` --,BOARD OF EALTH ................OF.......... ................. ................ (9rrfif ter of Twuutpliattrr T I CE Y, T}aat the Individual Sewage Disposal System constructed ( or Repaired, ( ) b ... ••• -----•. •--•--•--- Y--•- - ---.. .- •-•-- - --.. ;7,0--- al ...... .............:.•--•--------• - ----•------...----- Installer ...............................�-. x---------------_-- -- ----- . ---- has been installed in accordance with the provisions of T of Th State Sanitary Code' as escri d in the application for Disposal Works Construction Permit No'-'-_- d'ated__.�/�.w_�2`_�. :.............. THE ISSUANCE OF THIS CERTIFICATE SHALL-NOT BE CONSTRUED AS.,A.,GUARANTEE'THAT THE ' SYSTEk WILL FUNCTION' SATISFACTORY. DATE.... Inspector, --•------------------•---. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No................. FEE. , .....:.:.:• iunu or u, it�siun rrnti Permi io reby: grante ..:_._.. to Cos c a r Indavl a Sewage Dispos sit 4, at N �/ �`----------- V•• . ----- rA` Street .. pp p orks construction.Pe No ated._�, i7 ............. as shown on the a lication for Dis osal W .., / ,�� DATE.._ oard of Health A .�B (y� 9 N FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS y r . X 1-11,____l.l___.�,____ _-- ----_'-----:__.111__ l__ __________l______ I I'll�111-11 ____ ___ I � �1.___- I - 1 ____ _._________________ __ - , - _____-__- - - _ I - 11 11 � I I I - ---"-----________ I I�_ -_---- I— I-,-- � - , � : : - I I . I f---- � - I , � I � I - I I . � - . I I I . I �_ I I . �. � I . I , � . : I I I I . I I . - I I I I � I I I I I I I 1, . I I I I I I . I � F. F, 53,001 � � - I I - � I' ll , i I : I ,, , TYPICAL '. SYSTEM PROFILE 1� �., I I I � I I AREA PLAN .1 � � I FINISH GRADE-` 51.0 i � . � �,1,I�� .1,�, I I I . i I � I � I � FDN TOP I NOT TO SCALE � � : I I I I I i I is- 40, 1 1 i � .� � - I I I , � SCALE : I - - ) I I � 52,00, 1 1 FINISH GRADE OVER TANK= ,51 ,OC) 1 , I I I I FINISH , I I'll I I I I I � - . ll� ell 111.11,11, 11 27,-0, 7,-, p I� pqp"," -_ � GRADE OVER PIT_ 51 .-oo I .1 � . ( , _1� ', . I '' - I I I I � I . I .. . I .111-1111111111.......___ _,,l-_... , I � I � . I � " I I . � ,� I I l.., -1: _.l.. -.1 I I � I I � .'.;w..' '_ .. I .:�.".'.-I.- .14, . t��. . I . � " I I � I I I , - I I I . � �l : I I �,,� I ., ; . . I . I i . I I *1 � .1..... .......'_-4.�� ... .... -_ A I n I I - ___lp q .1 .., .. "' , - I ,- I -,"- 3 4 BET H S � - I .1 � :; * `_` "�4 �:.. i LOT LANE I I . .� - ..I. . .wwwww�',v�' 7t. .2 ,...... . . ..- _ -, ... . '.. - I . .1 .� - � - . . .;.:_ 11 I I I � . I . I . I 11 .. I... -- I : . I I I � I .. PVCOR " ,% Z? & _____ - " I 0 0 , _______:: ; � : : . : : 0 0 1 0 0 1 1 � . .. . .1. - ja I : I I 1 10:�61 1 1 1 . I ! � 11 - � I . . .. ... ,&7 .;,,-: .,. !t ;; i - I I . �,�C. 1. TEES . �**-' '. I ! 1 15 0 00 <= , F , , I I 11 I , i. :1 .,::--::I 1� , _. : I IIN � � I I I I f I � I I I � i .'. -11� ...�,' 1:-11 ' .1 T;WA �l � ! -, I I � I I '.. ,so �--,";.' . 0 0 a I I a .. : I I i BSMT �: I '. -c!:t� i I . ! I � I � ... 1000 .; I '% ', I I : I � I I � I I I 1 ,45,00% - 1. � I - GAL. ... 4' f I � . : : : : : 0 9 I % I I I I . I I I - FLR. ..% - ... 48,25' . ,.4 1 I � . :7 . . '. � . ,� . � I- ..� REINFORCED .:,.I- I . DIST. BOX .1. 60 I a I 4 0 0 1 I I I �- 11. ! � I � . I i I .. .. I Is I . . zv 1 7 1 . : � . 'I Y.. E ,, � -8 I ... I I � � I . 1� � � I I I :*. . r TO BE INSTALLED ON I 0 a I I I * . * I I I 0 4 , � I � I I I I :. : :: ..:;- - - . .. - - - I F;�, 71 "I 'l - ". I I . " / I *...."."...O"�.:.":�:*.:..4 .. . . *: , . -� -1 - �4 0 1 0 6 * - . . ,�. . � - - - A LEVEL STABLE BASE III 0 4 a I I I �� ! :0,,,a-...-.1� .. .'. �: ..--.��.-_`;�,_ -`-,_-,.;,;,-!�'.-'��:*.i� i - � ! ,-,-�.',,'�,.."P�-.`�-� . � : . - I . ) . . . . . , I . I i�. z J ! i I . I I I �l 4 6 0 6 6 0 0 0 9 s 0 1 � . I I . - � , ! 1. � 11 � I . I f I I T. ) I ;3 ,, j , . . 11 - SEPTIC TANK � . I I � i � I . � I I L_ It I 0 0 * * 6 0 0 to , � I , i I - I I I - I I IF Z �, ; I I I .1 TO BE INSTALLED ON A 1. I I I �_ 0 , 0 1 0 0 III I I I I I - I . I �_ I- , I � I I I I �!! , � i I I LEVEL STABLE BASE I . . : i � I I I . I I I . I . � _. . 0 I I 0 4 0 0 I I 1, , � I . I . 11 I I . I I I � � I . I I I . 11 � I . - I & 0 t a 0 0 6 1 11 i - I I I . 1, . I . � I � I . � I , I .ill t 1. I . � . % I .1 , i I I I I � I .11 I - �, I BRICK a,MORTAR COURSES AS AROUND FREE OF IRONS, FINES I 6 I 0 0 0 0 I 0 � : I . I I � I � . � REQUIRED TO BRING COVER TO GRADE I � u j , � . I I I � K . � 2"-1/8"- 1/2 "WASHED PEASTONE ALL' :�' � , : : � � : I, I � � I I I I . 1. I I I� � I I . I I I . I I I � I AND DUSTIN PLACE . i I I I I I I I � I � I I I � i . � . I I I I I � i " I 11 I I It . "" ' I _� LEACHING PIT , : I . . I I I I . -112 ":WASHED CRUSHED � I 1 24 3/4 TO I I � � - I . . I I I � I - . I I � � � � I � I I I � . � I I � ; I FRAME - SEE DETAIL STONE ALL AROUND FREE OF , - ' BASE TO - BE LEVEL , , �, I I . � I I I I I � 11 � I � I , I � I I . I � - -DUST IN � 1. I � �� I I I I . . I I � IRONS, FINES AND i � I � I � � I � I � I - I 11 I I ,� � � ,�, I ;_ I I, I I . : I I . PLACE ( ), REQD) I � I � "I 1 ,; � I I I I I I . � I I I � I � �. I � I I � I I I ., 11, � I � � 11 i � I I I I . � FOR FIN. GRADE I I . I 11 I I I I I I I . � ,� ! I I . . I I I . I I ll� 1� ., � .. I . . 11 i I I I � I .1 . I SEE SYSTEM PROFILE I . I � 11 11 I � . I I I : , I I I I I I I '� � I I � . I i . I � I I I � i I I � I � I I OLATION : I I 1 . I , I .1 I � I I Wift�WIF-11 t I I � I I � 177m= _ . I I I � I of .1 I I I I 11 I . 1 I I � I . I . ; � I I I 1 4 1 1 1 1 � I I � � I 11 . I - I I I I I I I I I I DATA -" I � - _ I I - I I I II i I � . .1111� I � . 1- 1 . � � I I � .I : I I I . � I I I I . � I � � � � � I I I I I I'll . - I I --- � . � I II I I I �I � I � �. . I 1.11 1�1 �l I I . .;111 I I - I , ; I I ____ __l I .. - - I I Ill I 'll � - I I 1, "', � I I I I I I � I , - � I � I A I I I I I - 11 � iI . I I I I' ll , � . . � I I I � � I I I I I . 1 ! I � � I I �,��, ��l I � I 11 . . � � '_ i � I � I I I � I . I . � � 11, " � I -, � 8 11 . -I; :.-:-.., .. -- I PERC. RATE : 1 ,/, 2 1 M I N./I N. � -- -I '1_ : i . I I I I I ! I 11 I 11, ) I � ---�-:.:�"' � I I t I--- _ - ., -.:.77T ,.,..,.,::...�*� , � , I 11 . . I I I I � - �I I I � I ., - I � �� ' . . �l . 1,�� ,-. " -7 , .� , , : �0 , " , , -, I � . I I I I I I � I I I 1� I I 1 ,/411 . I, . , 1. . . �0 - FOR ,INV. ELEV SEE ::Z: ,. . ,, . . , *' . I . � � 1,� iI . I I I I I-—_. - � 111 � , I I . , ' 01 I I . ' O , � I I i � � I � - I'�, I �_ I- - I I INLET -- ,, , " � ::: YSTEM PROFILE , z= '-7,'-7-;F-e is -�I,' ,I,,_' ' C. D. SPOHR - _�?� I I . I I 11 .I . . _1 . I I , ' ' , . TAKEN BY : � 1 I � I 11 I � i I I 1; I ��. I ' 'I - r � I �I- i , " ,.,.,"I I I 'IN" ju �. - - I I I � I ' MR. PAllul. mup.p-16.1y, . 1-1 , I I � . I 1 1 LINE ' , ', - - , 0 1 1 - 0 , a _r � . . � . I 1. i , . - . I . - . - - , " , �, ,� " I 'r ,wj . � I . I � I � I , 0 � I 11 - I WITNESSED BY: 5AXW5 ABLE 60, �X�og 14WALT1 , I I . c � . - 0 � ,. .,I. - . . I I 1-1 1 401 1 1 . � I I I-, I I I . ,- I , - , 0 , I - o OPENINGS W/4-1/8 , , . 1, . ''I I �'*_1 . 9 ., , 11 I I i� I .0 , - . I . "i :== , " " , " , " , . � 1 5 MC, '1978 , e � I ,�l I . �l I I I � I I I I 11 I I � I - " I I OUTER DIA. a 1 -3/4 __�_ -, . � ,� '15 , I I �DATE.' ______ I � �.�� 11 � I . , LANE ' � I ' ' I 'i 1", . I I t I ,, --:: 0 0 __�w . I I I I I I � . 11 -1 I . I B E T H S � I I I ." I I , I , I � INSIDE DIA. I I I "., 1 . 0 0 1 11 I 11 . - i I . I . : - - ,�" , 4 7 1 11 - I I- ' O I 11 , ," � I TEST PIT-GND ELEV.-_5 1.5 4 - 1-11 I I I ,� , � � l I ' ' , . ::- a 6 f, , '.1, I I � I I I I N . I , I I . I I I I 1 #4 , , E , - I ,?'_ !, , 16 1 1 TOTA L .1 , " , ,�- I I I I I . I 30 1 I I ,I �', � , ., . 0 0::::: I , I 1, I I I . I � I I �l I I - N 2 5 if '56 I . � � I - 0 , ' . , -1 - , 0 . , " "�� , 11 0 - I I . . � �� �_' "_l , - ., 0 - -= 0 0 1 � I I . I _ i 41 . / � . J , - I , I ,,� I _____l ,� .'' j ': I , , . I I I . I ,�� � � � , , , , , - AREA 0 - ." . I . � . I I . I � I I I I IL p - � % � 11�1 1� � I - I �, . :: 0 b 0 , ). I � � , I ". 1, I 1� I I i I � 1 ) 25,00 ,) " , - ., � . � � I I L 0 AN,M S - S, - I I � I I . ' I I - . . I I 0 6 - '. - (' I "I , ." . I I 6 , , , ct , -= I 0 0 . .. � . I .No, P,usr _" �:�' i I 1 � � I � I �; � I .1 1. ` ' I I 0 S. f* 0 0 0 :::� .I , , , * I ,�I . I - I : - I I 'm�>_ %_/ I � , . 1 I , 0 285 1, I - I .,.,:, LVEDGr I . I . 14 -TOWN,W-�\ : w L n"T033 I 1� -1. � " I I , 1 2 1, I I 1 . � � . I � I I - L � i � t . . I - . - . I " - , , _,.�a � . I I .1 . 1 . I ll� i � I � - - 0 , . --:: 0000 I 0 . " I . = = � . . � � , � I 11' .1,I , I , , ; , ,-0 ' . I � 11 I � - 0 D, 4 - 11 . _. , � �l :1 11 ; I I �. I , j I i I I I L 1,40 , w , I -A' 3 4 � � � � � � , ' . ( : i t:- 0 0 D 0 . � , I I 0 t I , � COAkSP_ olz W.ATE�z .I , I : , I Qj I , , I - - - , I � 0 1 1 . I I . 1. � I , I - I � I . � . 1 I .1 I - . _ _ - I ,. , : I I " e ,��,i 0 - I - � � I BROWN I I � , . "I - 1. . , I I ' 'I I -* I 0 �Fwur � ,'a. 0 , - '_4 ". No 0 0 Do . 0 0 0- 'r, I 1� " . "I., - � I . I � LOT � 0 LOT , cq . I 0 � I � I I ___�I_ I I I I 2Z 1 - 1 I . , I �-- I- -_ - ;, - ' . 1 � 0 0 1 1 - ' . I . . 11 . I - i � I I I - � I � I - __ I ..%wr_l_ - -_----. - ,�I - j �,�I-j I �I � i I I I I I � I I - , . (5 I D F-) � I 1 . 11 . � 4 1 1 1 1;f I � I --' -- SAW-D _____------- - , - _` � . PQO"Zb, I 11 I . I iI I I � � I I 1. � � � I I .� I I I A - . 2 66 I- 6 DIA. ,9 � I T " 00c I � I �1. . I � . I . N i , 1 a 15.m. 1*5 ) s r. 'T I . i � I . I .1 I 0 ve I 1, I � . _-*___lm__ -,.4 . )-i ot - - -, I- � I t1r) I Hou$ ' ' - to . I I - I - 0 1 � I . I I 1, I I I Ictoo' I -SEPT(c. I � . z 21 1 () I "I . i - 10' 6 " EFFECTIVE 'DIA., ' � I I I I � 11 ,GAL- ,f�,P_CCA'%-4�T, CONCREM 6 1 . 11 i I - I � � � I I � . � I I I - I I I I 11 - I I � -I 5 F_E PQOF-I LEE 11 11 a N 71� , () 40 1 1 . I � I �- - I I 11 I, . DOWN 3 G 11 � _i_ , , I I I 11 - I I I I I ) I� . . � � I I I " TANK . I I'D - 34�-j 10' .1 10 1 . - SECTION I . - I � - - 11 � I I ., ; . LEACHING PIT I . I- .. I 0 � I � . I .1 , � ? �� I � REQ ID) �--, V.2' a -1 � 11, I .. 1: I r- I N r- I .1 . I I I -1 I I 5 I I I I _."l 11 � I � I � I I � I r � I I / NO SCALE I .. I - . . . I,, �PRECA'ST COMCP>ETR 'DISTRI BUTIOM I � - I . � �1 . . 11 �,- I I 1, DESIGN DATA : Q I . 1 . I I I � I � �l I I . ' . I � I � _', I 13OX -\..O SIEE7 *PQ_0Fl LG I I . I 81 , - 5G11 RvAlk_ � I I I tl I NOTE: DO NOT RUNHEAVY EQUIPMENT OVER SYSTEM �'� 3 � "� . � I � I I - I.1 � � . I . I I I I , I I 11 I I . . N 0. OF BEDROOMS 1: .. I I � I . I � . 1 2 1 1 . i I . 1 ;7 1 � � I I I I -`1 Q DISPOSAL . I �l I � 1 2_ 1 ' I � p;Z�CAS-r Cof4CP_eTT� I-JEAC-kiNG PIT, I RFq " I OT,14. � . . � LEACHING PIT NOTES: I 1. . I � �� ' I � I . . I i - � - . \ I - I I EST. TOTAL DAILY EFFLUENT330 GALS'. . I I � 5EF PPOVILE '4 DFT'A ILS ' . Dil i 125.00 � I I - CONC. TO BE 4000 P.S.1 a ' I 11 SEPTIC TANKA2'00 GAL.- I ,� i , . I I I 11 � I I � �-0 5 1 y 2 5' 58": . Vy I I * I I Is Ito I I I � � � � I I � I- I I �z,� � I - . � I � . I I I � 2. REINF W 6 x 6 6 GA. W. W. M. 11 . "ll � I � � I I I I . . I I 11 � 11 - I � . . � � - I I I I 11 �I I I . . '.I I I I I I � I � , I I I � " . I I � � . � . 1 � I I I � 3. 2 AND 4 SECTIONS ARE AVAILABLE FOR ' .1� I I I . ''. i � I I I � I I � � I� I � . ,� I � . . � I I I I I I ,� I I ll� I . ,l ."I" I . ; GENERAL ' NOTES - I 1. � . I . I I . , I GREATER DEPTH REQUIREMENTS 1. , V I . � I I I I . I . � I . � , I I I" I I I I � 1, . I I , L I Z)�, - � "'� .1�.�1: ,�_ � � I 1. I . . I � I I I I , I ��_ i . . - � I I I � I � I I . . I � ,I , 1 . ALL SYSTEM,COMPONENTS SHALL BE INSTALLED IN I I I 1. 1, iI I . . . � . I NOT I I . I . � � ,� - I I L ,, i I I I I � I � - I � I � I � - � E: ��� I � I I : 1 - I ,K � I � � - ' ACCORDANCE WITH TITLE 5 OF THE STATE SANITARY CODE ' ' I - I - � - . I I I I � . I I I I I � � "w, I L. 1 � I I � I I I � I I I 1. I 11 I E XCAVATE TO .ELEV.-46','06 0 R LOWER AS � ' : 'DATED JULY 1 1977 a ANY LOCAL RULES APPLICABLE. I � � , I , I I . 11 �� 11 � . I � . � - I I . I � . I .., I I I I'll � 0 , � 1� ) - 1, �1 . I I I , REQUIRED TO REMOVE ALL LOAM AND CLAY CONTAINING �: � I I I I 11 �l I , � __ I � I I I � - 1, I � � i . OWNERS ,� � ' BU I LDER-0 I I I I . � - . . 1 I , I - 11 . 11 ' . -2* ANY CHANGE TO THIS PLAN MUST BE APPR D. BY THE - ,,': " ��il ! I .1 I ' � I .11 . I . 1, MATERIAL BENEATH PIT. REPLACE EXCAVATED MATERIAL � � � . i11 I . � J i � - --- ..� � . .1 � . � 1� I I I 1, I : I d . -, , I I 1, , I I � I � I ". I � . . - I I . I .1 BD. OF HEALTH I . � 11 , . I . � I � . I Fl � I : ��',l I I .WITH CLEAN CLAY FREE GRAVEL MECHANICALLY � � I ��' I,� - -I., I 11. I )'AND CHA I RLES D., SPOHR. 11 I ,� �l 11 - " -�,�, , .1 L I ' � I 'e,WN _F 1.� � . � � I I I I I , ,�, � -, ! CLAP,l<_4,_T0 _-BUILD .VZS ' - � I 11.1 . I . I I . I ill � � I I I I �� - � � . I I I . � , I I � ',,',3. ,WHEN CONSTRUCTION IS COMPLETED, PRIOR TO BAC � � , I . ,, -.%, I - 11 , , � I I "I I I COMPACTEDJN PLACE. I � I � I ��- �,�'�l ,- ,�" ' 7 L I � . -KFILLING,:",, I I � . . I � � � i I I - � . L I - . "I 1, I I 1_.��, I' B.A'C 0 W' f^P,M ,.R0A,�0 I� I � . I I � I I � � . - � I . I- I i � - I "NOTIFY THE ENGINEER FOR INSPECTION. _ I "I I - � I . I � 8 ��l I � - � - I . I FA = -1 13 s. F.G_ -A ,S � - 'llq . I -,� � I , I - - 11 . � . ll�l I I , I ,i� SIDE' AR A -_ .F./GAL �, GALS� ' ' I , 1, � � � 11 I � � 11 - : I � - I . I I �,� �` 7 � '%�_ L ' I I I, I �,-,' I I , � I �� I I I I . I ��, , -1 4. FOUNDATION ELEV. MUST BE CHECKED WHEN COMPLETED. '- " - I ,io ' ,. I "I 11 I �l I I I I I � � 1p 1. - . ; � FA�_"O,UtH ',�--imogl.%Sts , . � I . � I , I �l _ , � I -, I - : - I I f , - I I I I I I I �:,�:"� ,, I . 87 @ ,0 1 ". I , I I I i I . lll� � I . : � I �, ' ' .1 1 ,4, I �11 I . IL 1.I ,� .11 . I � � . I I I � I � - . I � I� � - � I I � BOTTOM AREA= , S.F. - S. F/GAL- 8 7 , - GALS I�., - .;_ � I I 11--, I . ,� 11 � I 11 ,, I � I I I � L - . I . �� I � , - . - . I I � I- I I 11 � 11, 11 �, - . I I L , I `� '4 1 1 1 � � � 1� I . I I I I I I � , I . � ' � 1, I . T WR I TTEN I ,�, ,4� L I . . . � . 11. �, I - I : 1, - 1: I I I I I 1 I - I 1 � � : 11 . 11. .: I ' � TOTAL AREA = S. F I I I I I � _82, ., ._: ` "5 ,THESE ELEVS. MUST NOT BE CHANGED WITHOU I � I 11 I L I TOTAL ' , 1,s � � I I I I I � .1 I I . -1 I � GAL'8L,', il '� , ' .1 I ' ll, I ,, L . I _` ,� � z� I . - � I . 1 I ,, �1, I . I . I . 11 I I � I . I � I I I I � I " I " ,� - 1 : ,, "I'll '. � I 11 " 1, I - I I I I I : I I . � -, " I I I", I � - I I I "I' 11 11 , I ,I 1'1�, - ,,:, APPROVAL BY CHARLES,D. SPOH R. I I - "I I I . 1 - - , , 1 . �l I - , � _1 %�, - . I . _.. . , � N, I I , � � � � ; i , I : ., �, - I I I- I I I I (.1', ��� 1 I .l.. � ,_ ��l .� . I L I I � �_ 1, , I , . I,� � . 1 '. I �, � , � .1 �l �. � I I 11,",11,"I 11 � " � �l" .." 'I, '' I i I 1. I I . � 1, -�- , , ���' I � I � : I I 1- 1 I . � "I�,_ 1* : �, I � ' � � � � IF 1_�,11, _', , 11, , I � � I , "i. , I I" I � � . LEGEND. : " I - - ' 11 � , '�,�.,-L�'Tt- FOUNDATID"8' ' XCAVATEDi I'I,,"�- - 1 . ,::, �,-, -��, I . .� I 11 I I � 1 i .1 B. m ,-,N OTE, � !"�,, I 1�� - ; � �� � � . I I . I I , I _1 I .1� . % I . I 1, : , , I �l ''I -, - - PECTION REQD. WHEN E ' . � ,�', 11 ' . , � I I . . ,-. I I �, , 1, -� I- i I � 1. . I - - � 1, 1. -,�� ". � , , �_ . I � _',�vl , ' , p J>j:� I I , �� � " , , `-, , - " � I . I I I � � - I _ff � L ' . I � I I I I 11 I I I— I I � I �l � , � - � e� I - - � 11 e", I 1�; , I i �l �. . I - I - I I . - I ,� , :,�' . i � I I I 11-11 I � � I .� 1. ' 'I 'll ," I ,_�,, ��; I I'- 1�, �I ., I .11 I , I I � � , , - I I � . � I I L. , ,� , I � I- I � I -1 I 1, -11. 11 I I I I 1� "I - I � ,�ll� I " . , 1:-� I- _'N""' A EMEW.T I _1 I I . � 11 - .1, 1 . I 1, , : .1 ll .' ,1: � : L, ,,+ , , I ;� � I I I 1 o'_�, I , , .1.1�,J:_�' ':, - - '_ �l I ; /'- - � -,. '_ . 1;�_111� . 11-11, I I ' ' :'EILEVS ' ''B'A�S I 0" O' �_ ly " ' , ''I I � � ,�� .1 � ,� 1, , � _: " , " I_.,�,:l . �� I � :, �� �� - � 1 : 0A : I I I I 1 , , . , , �; - � Al_L_ - �.. - � � I I . . I � . . I "': I - "I ,:� �,'; � �, � - - I .p ,-, ,--, : ' 'L ' I -1,;l e., - l-, , I I I I � 1", " �_ - I � I -e,�1� � I - - -, '' I - I �l I I I 1,,,�,, ,���_. -,, ,'' �- I , I , - I I � !l I - 1 , 1 - �EXIST.. GROUND ,ELtV. '� *:�� ,_` � � I---I I I . � I � m, 11 , . - - I I � I � I . I , I I �_ 50.0 , , . ,-, , , " .�, 111 . I " I 'll I � I - � I _� , ";-. �1, ll�l I . I _ 11 I ". I ,.�, :,I�i ,�, ,�,l I - I I _." �� " 1.I'_ , -11 ,: 11, � I _ .� , 11 - , I . -11, � I I I _�I I , I � I L., I �._ _ � I� � ." I , , , - I I � I , v .1,, - .I I . - , ., - - I I � I � - � I : - , , , � �,���I � '. .,�- - I_� ,�,., � 1, � , . � 11 I 1� I 11 11�. 1 ,�, I" " �,;,��'' � -4",�,'� I I� ��, - , , � , , I I I I � I ;;l 11 ", - - ' - - :, � - ' '!!EZU_]�ASD-,7`E_LF.,V �50-,100 --l- I , 1; . 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