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HomeMy WebLinkAbout0015 FIFTH AVENUE (HYANNIS) - Health `-l5 Fifth Avenue. Hyannis P A = 246 195 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION �y Sr, DEC 15 2004 TOWN OF BAPNS'Ab .E TITLE 5 HEA, H DE PT. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION AP Property Address;,A' - OT �i5 l k Owner's Name:. Owner's Address: Date of Inspection: Name of Inspector: (please printj}6ug ac A.Brown Company Name: L7nunhc o Brown Septic Inspections Mailing Address: an Q..► �d� Telephone Number: A 02W2 CERTIFICATION STATEMENT 1 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 Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signatur . Date: The system inspector shall sub it a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments ****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. t,. Title 5 Inspection Form 6/15/2000 page I �w�s�c� A-d IC13t/2aV t Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 11111/5- Owner's Name: Owner's Address:. Date of Inspection: o--C3 f Inspection Summary: Check A,B,C,D or E J AL WAY complete all of Section D A. System es: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CUR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: one or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the following statements.H"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 extiltration or tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed Page 3 of 11 t OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: lS , sNrNi ,t Owner's Name: to Owner's Address: . Date of Inspection: 19-a -f]2 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(l)(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 functioningin a manner that protects the public h p c health,safetyand environment: p _ the system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**.Method used to determine distance **This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form 3. Other: • • T..�,. J �C 11 ' v I� OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address• ,,-�iS -` d v-2 r'4 Owner's Name•_ ,� Owner's Address: Date of Inspection: j 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 ces l og clogged ge or pondmg of effluent to the surface of the � SAS or cesspool ground or surface waters due to an overloaded or — `�'fatic liquid level in the distribution box above outlet invert' due to an e ov rloaded or clog ged SAS S or ces ool . � d 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 1�mes pumped_ _ portion of the SAS,cesspool or privy is below high ground water elevation. Portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. — y portion of a cesspool or privy is within a Zone 1 of a public well. _ --e--An-y portion of a cesspool or privy is within 50 feet of a private water supply well. Y portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (-V- t� (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 8Td• You must indicate either`yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ - the system is within 400 feet of a surface 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 CUR Page 5 of 11 OFFICIAL INSPECTION.FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address? s � r to Owner• �,fZ lC Date of Inspect on: Cc- 4 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 �e any of the system components pumped out in the previous two weeks? Nt7•z� 0 c tc A- —Haems the system received normal flows in the previous two week period? ve 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? _ _e�Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes V Exis ' g information.For.exam lea plan at the Board of Health. P � 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)J 1 -Poe- A-o "DeFV h �i3 wcx5 JOIr o(P�c�J 5 Page 6 of 11 OFFICIAL INSPECTION _ FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: # S r� A d .e Owner's Name: Owner's Address• Date of Inspection* RESIDENTIAL FLOW CONDITIONS Number of bedrooms(design): ,3 Number of bedrooms(actual)' example: 110 DESIGN flow based on 310 CMR 15.203(for a Number of current residents: O gpd x#of bedrooms):33U Does residence have a garbage grinder(yes or no):A*0 eparate La dry on a insp�ed(yes osewage rY�m or no):p)[if Yes separate inspection required] Laundry system' Seasonal use: (yes or no):— Water meter readings,if available(last 2 years usage(gpd)): Sump Pump(Yes or no): Last date of occupancy: COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow(based on 310 CMR 15.203): Basis of design flow(seats/persons/sgft,etc.): r Grease ease trap present(yes or.no):_ al waste holding tank present(yes or no):— Non-sanitary waste discharged to the Title 5 system m es or Water (Y no Last date of occupancy/use:�' available: ) — cupancy/use: OTHER(describe): Pumping Records GENERAL INFORMATION Source of information: Was system pumped as part of the inspection(yes Yes,volume pumped:______dons--How was Reas�o�n�forr limping: q��9 pumped determined? Ty��r'aYSTEM Septic tank,distribution box, soil absorption system _Single cesspool —Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection_Innovative/Altemative technology. Attach a copy of the current recur ds'if any) obtained from.system owner) operation and maintenance contract(to be 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 arrivina at the site lees or no): per' r . Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ASSESSMENTS PART C SYSTEM INFORMATION(continued) Property Address:. *-/S s fi\ is g u�r ttii i. Owner's Name: Owner's Address: Date of Inspection: ..( BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction:_cast iron 40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:_,(locate on site plan) Depth below grade:12�L Material of construction:�crete_metal fiberglass___polyethylene other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):—(attach a certificate) p copy of Dimensions: a Sludge depth: tf� Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness:'-t Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural irate as related to outlet invert,evi of leakage,etc.): gntY,hgiud levels GREASE TRAP:_(locate on site plan) Depth below grade:- 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: . Comments(on pumping recommendations,inlet and outlet tee or baffle conditio structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): n' Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address./-/ 5 t v e 1 i � Owner's Name:� •�r CC Owner's Address:. Date of Inspection: TIGHT or HOLDING TANK: (tank must be pumped at time of mspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: aaLons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of jeak-age into or out of boxLe k etc.):— PUMP CHAMBER: _locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C Property Address C,+Ih S STEM INFORMATION(continued) %j co Owner's Name: _R H naA(i C Owner's Address: Date of Inspection: SOIL ABSORPTION SYSTEM(SAS):—(locate on site plan,excavation not required) . N SAS not located e lain wh O Typ - leaching pits,number: leaching chambers,number leaching galleries,number leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): , T 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 or 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.): _ 1 v t I + Page 10 of 11 OFFICIAL INSPECTION FORM—NOT.FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address SA Owner's Name:_ Flt,c 1C Owner's Address: Date of Inspection: ( SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including tics to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. O ,30 Cr f Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C YSTEM INFORMATION(continued) Property Address: ge -'IV)- Q Owner's Name: Owner's Address: Date of Inspection: SITE EXAM Slope% 4-p k'2l Surface water% ry 4,A 'e— Check cellar: p/•t Shallow wells Zo v 2 (- Estimated depth to ground water AZ feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole.within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: / �w.:J /�v' r✓ ��.�` � a r a� iz' 2 � NG� G..lcJ �,mac�,d� 1-r�r�C� yy r TOWN OF BARNSTABLE LOCATION SEWAGE # LAVE ® d` ASSESSOR'S MAP &,LOT INSTALLER'S NAME & PHONE NO. p�- el z g�� SEPTIC TANK CAPACITY `®Q t) �)9 I• LEACHING FACILITY:(type) 1000 6X(o (size) Z ' Sio e NO. OF BEDROOMS Z PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER ®C90r Ni tl s DATE.PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No __ J 4 �j. rr y r� o THE COMMONWEALTH OF _MASSACHUSETTS aye, ,q BOAR® OF HEALTH V ------------------- 0 F.... 1A 51rw. ....................................................... Apli iratinn for Uhipmal Workii Tnnittrn.rtinn ramit Application is hereby made for a Permit to Construct (x) or Repair ( ) an Individual Sewage Disposal System at: ................_............................................................................... ...... .._........----•.•---- ----------..........--•-•............-•--- Location-Address or Lot No. -- •---•----------•---•------....� .._ ��^ ...................................................•...... Owner , / Address ....................•---•---........--------•-•-•----•------•--.........._••----•--•........------ ...U!re` F.I.t11� --..... Installer Address UType of Building x Size Lot..._/� ....Sq. feet a Dwelling—No. of Bedrooms...11 Expansion Attic (ilb) Garbage Grinder ¢Vb) p, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) p' Other fixtures .................... . . WDesign Flow.................................:5.5._.gallons per person per day. ,Total daily flow______........................�30...gallons. WSeptic Tank—Liquid capacity..l agallons Length__S..�6..... Width._ ..1C.. Diameter..:^--'_ Depth 5_.L-._....--.. x Disposal Trench—No.____------•-.-._ --• Width.................... Total Length.......... Total leaching area....................sq. ft. Seepage Pit No.....07-Wr--.-_--- Diameter-----1Q-.__:___. Depth below inlet....46............ Total leaching area..a�Z....sq. ft. Z Other Distribution box (X ) Dosing tank ( ) Percolation Test Results Performed by. y- I& . . fka f2��_:S,.9etLt saY Date___/_Z--11.787.--......... Test Pit No. 1----a--------minutes per inch Depth of Test Pit------/ _.------ Depth to ground water---_---__-----_--- (i, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground w ...... OF a� Description of Soil----S?_-.Q�.--...-��`-vc�n=�-...........................................................................-.............. (� �'� .f r.G�Q SaCli.l. s.S2laYtd6 ................ ............................................. _.._...... A,±_Y�---- �y W i_$.._-.15�----trvm -fi �2�ccQtam_. , r�©.so2ls x Nature of Repairs or Alterations Answer when applicable......................................................... . fiL�02_ . U •------•-•-••••------P-••-••-••••-••---••-••--•-•--••••-••••-•--•-•-••-•-•----•••••--•-PP-•-•-•-••---•--••••••••----------•••-•-••••-•-•-••••••--•-•••-•••--•• �� Agreement: s G,rv>G' The undersigned agrees to install the aforedescribed Individual Sewage Disposal S stem i a o[ l with�>/d the.provisions of TITLE 5 of the State Environmental Cod. —The and rsigned fu t r agrees not to place the system in operation until a Certificate of Complian�has en issued b e bo rd o lth. ( Signed -------- ----------- .. o . ......... .............. ate Application Approved BY .. .......... . -- ..................................................... .....►/�f -lTo--o-�.. Application Disapproved for the following reasons: ............. 7�7--------------------------------------------...............---....-----------.................. ......... .... . ...................................... Date Permit No. ��¢' ----------------------------- Issued ..........i at/ _ t THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH -------.�awa-------------------OF....l rlt r�s'�. � ... Appliration for Uispoii al Works Tomitrnrtann Fermi# Application is hereby made for a Permit to Construct (x) or Repair ( ) an Individual Sewage Disposal System at: •...............-----•---...---....._ ..--- •-------------............_........... ---,Go-�-Z----.._.......-------- -------•-••---.........................--- ... ... Location-Address l or Lot No. �.uaku os....3:�cxa �a .I -V.-................................... ... �!! n - ....................................... Owner Address W ---•-•------••---•.................................•..........----------•-••---••-•--------------- .../ . .... nr ... ---------------------------------------- I �a Installer Address dType of Building Size Lot___-12.1 ----Sq. feet V g— .__..Expansion Attic 0 0) Garbage Grinder,ea) Dwelling No. of Bedrooms___ _ ____________________ Other—T e of Building No. of persons............................ Showers — Cafeteria Q' Other fixtures .................... . .. d - --- ----- --- ------------------------ W Design Flow.................................5.1__..gallons per person per day. Total daily�tflow._______..__.___.__._...._..._�' R....gallor WSeptic Tank—Liquid capacity.1�4.gallons Length__ !n&..... Width.'"».____ Diameter-- -""_- DepthS._:_k..... x Disposal Trench—No. .................... Width.................... Total Length....____,T--------- Total leaching area....................sq. ft. Seepage Pit No.___- ......... Diameter-----l_Q......... Depth below inlet...�............ Total leaching area..A 7....sq. ft. Z Other Distribution box (X ) Dosing tank ( ) Percolation Test Results Performed by.ieYy.-tr--A& g..f.4.--l-y11GC_._.,��.�t(�l�Sr Date.._/a_.-/' .'gy a� Test Pit No. L.-2 per inch Depth of Test Pit------ Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground VV- ........ ------•-------------------------....................................................................................... ..... O _ It Description of Soil----v-----�-----.&uKlrue,l.t----------------•---------•-•--------------- -------------------------------------------- --&TfPi•FEW- - _(_ _Gru �---------••-• .....ALLY-N....... w _.. _.� � - r lt4ltll v ------ILSO-------- --- ----------------------••----------- UNature of Repairs or Alterations—Answer when applicable-------------------------------------------------------- 9�........ Q ------------------•-----••--•---------•---•---•-----•--•--•-•-•------•--•-•----•--•--•-----------•-----•------............---...-----------•--•-------•--•---•---•- G/5T Agreement: D The undersigned agrees .to install the aforedescribed Individual Sewage Disposal System ' ac ce wither j71* the provisions of TITLE 5 of the State Environmental Co�e—The and rsig d f t �r agrees not to place the system in operation until a Certificate of Complianc%has been issued byyi e bo rd o h alth. L� Signed -....../..--... .... Application ---------- �. e Application Approved BY --------------------------------------------------- ----- �e Application Disapproved for the following reasons- --------------- .......-------------- ........................................................................ ....................... ...------------------------..............------------------------------------------------------------. ----- ---- - Date Permit No. 9e .............................. Issued ..... ............. -------------- > Dat THE COMMONWEALTH OF MASSACHUSETTS �-� BOARD OF HEALTH ................... OF ..... ----....-------------..... ----------P----............------------------- C�e>r#ifirtt#e Df �rtutylian e THIS 1 0 ERTIF , Tha Individual Sewage Disposal System constructed or Repaired ( ) by ---.`---- -- --- ------------- -------------------------- Installer p at `�i ._... .....- �^ - l..fi.-_ .......�1 l............... .......Aht .................-------------------------------------- has been installed in accordance with the provisions of TITLE 5 of Environmental Code as de ribed in the application for Disposal Works Construction Permit No. .......-� ............. dated -....1�.--�..J�--�.---------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUAR NT THAT THE SYSTEM WILL FUNCTION SATISFACTORY. .r --------------------------------------- Inspector . l;X - �... DATE.............�---...------... ................�� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH I:::"~o.. �1...$..� �5��..N FEE..A.................... nrkii nnMY." rrmit Permission i hereby granted...... .. . .. to Construct (6�) WRepair ( In j ldual ewa a Disposal Sy em at No. Street // G as shown on the application for Disposal Works Construction Permit No... .;. _.."" ated...__s_�_,1--- ... ..................... /° ........................................IL • ...................................................... / _ Q / ........................................ Board of Health �-- DATE-------------------- ---------.---- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS 20' MINIMUM OR AS INDICATED ON PLAN NOTES: T ,� 10' MIN. 1. ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO D.E.Q.E. MASONRY R R EXTENSION TO 12' TITLE 5 THE TOWN OF _ �5[5 T'7- ELF RULES AND TOP OF FOUNDATION 8• MIN BAp(FlLL WITH Z2'g REGULATIONS FOR THE SUBSURFACE DISPOSAL OF SEWAGE; 4 `� 3. O 22• CLEAN SAND � AND THE REQUIREMENTS OF THIS PLAN. Z�. MASONRY EXTENSION TO 12• q BELOW GRADE 1b 10 2. ALL. COVERS TO SANITARY UNITS SHALL BE BROUGHT TO +, �5 _ v WITHIN 12" OF FINISHED GRADE. rj 4• SCH. 40 PVC PIPE 3. ALL MASONRY UNITS USED TO BRING COVERS TO GRADE MIN. PITCH 1/8• PER FT. "4C T. FLOW UNE 2• LAYER of SHALL BE MORTARED IN PLACE.10• rEE 1/8• - 1/2- 4. ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE CAPABLE A 0O6WASHED STONE �OF WITHSTANDING H-10 LOADING UNLESS THEY ARE UNDER OR �• MIN. F Ga / EVEL GALLON WITHIN 10 FT. OF DRIVES OR PARKING AREAS. H-20 LOADING �'h2• YIN. LEVEI W LEACH Mm. /( ?J, �;'y 7 PIT 3/4• 1 1/2• SHALL BE USED UNDER OR WITHIN 10 FT. OF DRIVES OR If-C-hrrE,elr,L E�`�. LIQUID — WASHED STONE PARKING. LEVEL DISTRIBUTION ;q, ' Box < 5. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH DEED W 13,5_ RESTRICTIONS OR' ZONING REGULATIONS. OWNER/APPLICANT SHALL �d 5GAL C� L� 104 GALLON SEPTIC TANK OBTAIN SUCH DETERMINATION FROM THE APPROPRIATE AUTHORITY. LOCATION MAP l I _ � z_ 6. HORIZONTAL AND VERTICAL CONTROL, SEE LEVY, ELDREDGE ASSESSORS MAP Z'¢� PARCEL a & WAGNER FIELD NOTEBOOK UQUID DEPTH IN SEPTIC TANK DEPTH OF OUTLET TEE BELOW FLOW LINE BOTTOM OF TEST HOLE �. 4 FEET 14 INCHES S FEET 19 INCHES OR USGS PROBABLE HIGH WATER LEVEL 6 FEET 24 INCHES CURRENT ZONING INTERPRETATION: �'� DESIGN CALCULATIONS --------- .. ___� SEWAGE DISPOSAL SYSTEM PROFILE MIN. FRONT SETBACK Zo__ FEET NUMBER OF BEDROOMS NOT TO SCALE ���/GV/ �E /D GARBAGE DISPOSAL UNIT ,yc -- _ F,4C,y ,� , MIN. SIDE SETBACK FEET TOTAL ESTIMATED FLOW _45N A4AI,+Ze - ON MIN. REAR SETBA K / O FEET ( /1G GAL./BR.!DAY X BR.) - GAL. /DAY �j �✓J71eA�clT �L. _ /B `�/ (J�/G✓D) —�� REQUIRED SEPTIC TANK CAPACITY _ GAL. ACTUAL SIZE OF SEPTIC TANK 1200 GAL. PERCOLATION SOIL TEST LEACHING AREA REQUIREMENTS SIDEWALL AREA ?,5 GPD./S.F. BOTTOM AREA _ /, c GPD./S.F. DATE OF SOIL TEST /Z. /'� -B9 TEST BY — SIDEWALL 27f( /o ;2)(�)SF x Z.� GPD/SF = �7% GAL/DAY WITNESSED BY � I.c/�So�! LO7 —5,/4_ -- BOTTOM IT (0/2)2 SF x /��% GPD/SF = �_ GAL/DAY _�D ��ie_eY - B.a�t� W j PERCOLATION RATE G__Z___ - MIN./INCH 267 SF 5-49 GAL/DAY Z E TEST PIT #1 TEST PIT #2 BREAKOUT CALCULATION: ZZ j i ELEV.= 2/, 7 ELEV.= I ..0 00, ii+vE.lik4j f r --0.00 ►--- --- /Do uo QT iAl- I s jj EXISTING SPOT ELEVATION OOXU t 1 rp� EXISTING CONTOUR-------00-- -- ,L1 /Z� 9`f f S,F FINAL SPOT ELEVATION 00.0 { FINAL CONTOUR 7P BOTTOM OF TEST HOLE 7 BOTTOM OF TEST HOLE SOIL TEST PIT LOCATION LO r f OR WATER ELEV. �' _ OR WATER ELEV. TOWN WATER --W W -- � � SEPTIC TANK DISTRIBUTION BOX ❑ I WATER LEVEL ADJUSTMENT: PRIMARY LEACHING PIT O I RESERVE LEACHING PIT 2 Z TEST DATE WATER LEVEL INDEX WELL WATER LEVEL RANGE ZONE -- - 1 0Z/?190 INITIAL ISSUE SAW DEPTH TO WATER LEVEL. FOR INDEX WELL NO. DATE DESCRIPTION BY � { ,,,- � V � �'• � FOR MONTH OF: --- -- - 5. WATER LEVEL ADJUSTMENT - - OF //�� � DEPTH TO HIGH WATER LOT Z /'1FTH 14vr= .01 Fok OF'Af i i STEPHEN V' jot zo' APPROVED: BOARD OF HEALTH ALLYNWILSON go ' �, A s SCALE: / = ZO JOB NO. � , I a/STE��� SITE i PLAN � ' 14 DATE AGENT /ONA LEVY, ELDREDGE & WAGNER ASSOCIATES INC. I.►NDS o AKMM PLOW Lm SURMORS Jsr�F /tioM4S. StF,+NNoAf N�F c,�vc,A S ?�I�s� � PERMIT # 889 WEST MAIN STREET CENTERVU-U MA 02632 NEW ENGLAND REPROGRAPHfCS&SUPPL Y CO