HomeMy WebLinkAbout0018 HOLIDAY LANE - Health 18 HOLIDAY LANE,HYANNIS
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TOWN OF BARNSTABLE eL
LOCATION C� \��ul �� • SEWAGE # 3 7
VILLAGE (1,X �N�c ���� ASSESSOR'S MAP &LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) �. ��p t 1 C (size)
NO.OF BEDROOMS
BUILDER OR OWNER UyN lS
RpPIKe D- �Y
SATE: COMPLIANCE DATE: a -zg-;zoo I
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply.Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) , _ ' Feet
Furnished by �-�C��� Y 7 7 ��
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� No. ��-�1�:� =- .. Fee
50-
�Y THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: —v—✓
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
Zipplicatton for �Di$ oal *potent Cun!5tructiun Permit
Application for a Permit to Construct( . )Repair(✓)Upgrade( )Abandon( ) ❑Complete System LJ Individual Components
Location Address or Lot No. ��1 Name,Address and Tel.No.
,g Qy Owner's���1� �����,�
Assessor's Map/Parcel t,/, � lml�l ,Dl�
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
7/9�
Type of Building:
Dwelling No.of Bedrooms k1 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
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 so ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by t 's Boar of H alt
Signed Date
Application Approved by (t, Date k
Application Disapproved for the following reasons
Permit No. " �lD�? Date Issued Eilzil W
r, 'it No: -T Fee
Entered in computer:
THE COMMONWEALTH OF MASSACHUSETTS' p Y"es L/
PU1�IC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS
'IV �.
2pplica.tion for Migpool *pgtern Construction Permit
Application for a Permit to Construct( )Repair(V/)Upgrade( )Abandon( ) ❑Complete System M Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No.
/� m00% '7-ay ��, _r�w�n s, ;V��
Assessor's Map/Parcel /,/ /7 r �/' '
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
7 7i
Type of Building: �{
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building eWee-No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
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 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by th's Bo d of al -
Signed Date
Application Approved by 0, . �'` Date
k`a" -a t U
Application Disapproved for the following reasons
Permit No. Om __Xo� Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of (Compliance
THIS IS TO CERTIFY,that the n-sitp Sewa a Disposal System Constructed( )Repaired Upgraded( )
Abandoned( )by l��d Ol�lDrIS _
at D G� . wi /� �J,`!%3 !/ has been constructed.in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. dated y U 1 .
Installer Designer
The issuance of this ,ermit shall not be construed as a guarantee that the sy em v�i 1 function as designed.
Date i 7 k ?ve I Inspector _K-
t
No. �(� �1--�� ---------- — Za 7 %D7 Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
Mig;pool *p.5tem ongtruction Permit
to Constru t Re air k Upgrade Abandon _.
Permission is hereby granted ,( ( ) pg ( ) ( )
System located at0//� "% �if
and as described in 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(must be completed within three years of the date of this perrrr t.
Date: !`�1 Approved by
FR011 . J01-11 REALT`r' FAX hdU. 508 362 IC-0 " 'iiec.� 11 2001 11:33AM P-
12 06/2001 2e:48 �,�ig��ias_��, JOH�-d GRACI SEPTIC PAGE 10..
age'10 of i l
OFFICIAL INSPFECI'ION FORM—NO i )FOR VOLUNTARY UNTARY ASSESSM.E�g'S
SUBSURFACE SFWACE DISPOSAL SYSTEM INSPECTION FORM
PART C
5YSTE`M II I`O&NIATION(continued)
Property Address. 19 J40LIDAY LANE WEST HY'AN.NIS11"O!RT,MA,0202
OwIler: Imo.SPIVAK
Date of Inspocdon: 812/0I
SKETCH OF SEWAGE:DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system includinp,ties to at least two permanent reference landrnark3 or btrichritarks.
Locate all wells within 100 feet.Locate where public water supply enters the building.
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TOWN OF BARNSTABLE eC
LOCATION I 1\��-� �� . SEWAGE # ud ' 7� 7
VILLAGE
NiS ASSESSOR'S MAP & OT-Q--=1*
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY ' C)_C� v4-
LEACHING FACMrI Y: (type) !E)% t 1 C (size} a , 10 b� ifi
NO.OF BEDROOMS _
BUILDER OR OWNER 41vma RpplVL@ K
SATE: COMPLIANCE DATE: ia-zB-xrr'�
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility �1' Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Vat! Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) N Feet
Furnished by.
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—o'1`I'�v f31- 11,b�
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3- 3lt 63-
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LOCAT, e IO�N - ��
`fi SEWAGE PERMIT�i E��
VILLAGE - —
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INSTALLERS NAME ADDRESS
�14-If �
R U I L D E 0 OR OWN ER
DATE PERMIT ISSUED
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DAT E COMPLIANCE ISSUED S_ 5 ,
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12/06/2001 20:48 5085647270 JOHN GRACI SEPTIC PAGE 01
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
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TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 18 HOLIDAX LANE WEST HYANNISPORT,MA 02672
Owner's Name: MR.SPIVAK
Owner's Address: 18 HOLIDAY LANE WEST HYANNISPORT,MA 02672
Date of Inspection;8/2/01
Name of Inspector:(please print) JOHN GRACI
Company Name- SEPTIC INSPECTIONS
Mailing Address: P.O.BOX 2119 TEATICKET,MA.02536
Telephone Number;508-564-6813 FAX 508-564-7270
CERTIFICATION STATEMENT
1 certify that 1 have personally inspected the sewage disposal system at this address and that the information repotted 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 aim a DEP approved system
inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
_ Passes
X Conditionally#635cs
_ Needs Furt Ylvaluation by the Local Approving Authority
Fails
9
Inspector's Signature: Date: 8/2/01
The system inspector shall sub mi copy of this inspection report to the Approving Authority(Board of Health or DEP)within
30 days of completing this inspe ion. 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
THE SYSTEM CONDITIONALLY PASSES TITLE V INSPECITON.THE DISTRIBUTION BOX IS BROKEN AND
NEEDS TO BE REPLACED.
****This report only describes conditions at the time of inspection and under the conditions of use at that time.This
inspection does not address haw the system will perform in the future under the same or different conditions of use.
12/06/2001 20:48 5085647270 JOHN GRACI SEPTIC PAGE 11
Page I I of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 18 HOLIDAY LANE WEST HYANNISPORT,MA 02672
Owner: MR.SPIVAK
Date of Inspection: 8/2/01
SITE EXAM
_Slope
_Surface water
Check cellar
Shallow wells
Estimated depth to ground water 10 feet
Please indicate(check)all methods used to determine the high ground water elevation:
NO Obtained from system design plans on record-If checked,date of design plan reviewed: a/a
NO Observed site(abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board of Health-explain:n/a
NO Checked with local excavators,installers-(attach documentation)
YES Accessed USGS database-explain: ala
You must describe how you established the high ground water elevation:
USGS MAPS AND CHARTS- 10+ FEET
12/06/2001 20:48 5085647270 JOHN GRACI SEPTIC PAGE 10
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property.Address: 18 HOLIDAY LANE WEST HYANNISPORT,MA 02672
Owner: MR SPIVAK
Date of inspection: 812101
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.
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AC 31 �
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12/06/2001 20:48 5085647270 JOHN GRACI SEPTIC PAGE 09
Page 9 of l l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: I8 HOLIDAY LANE WEST HYANNISPORT,MA 02672
Owner: MR.SPIVAK
Date of Inspection: 8/2/0I
SOIL ABSORPTION SYSTEM(SAS): % (locate on site plan,excavation not required)
If SAS not located explain why:
n/a
Type
1000 GAL 6' X 6' leaching pits, number: Y
n/a leaching chambers, number. n/a
n/a leaching galleries, number: n/a
n/a leaching trenches, number, length: n/a
n/a leaching fields, number: n1a
n/a overflow cesspool, number: ni'a
n/a innovative/altemative system
Type/name of technology: n1a
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.):
THE LEACH PITS APPEAR TO BE FUNCTIONING PROPERLVAND SHOW NO SIGN OF HYDRAULIC
FAILURE.
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: n/a
Depth—top of liquid to inlet invert: n/a
Depth of solids layer: n/a
Depth of scum layer: n/a
Dimensions of cesspool: n/a
Materials of construction: n/a
Indication of groundwater inflow(yes or no): NO
Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
PRIVY: (locate on site plan)
Materials of construction:n/a
Dimensions: n/a
Depth of solids:n/a
Continents(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
9
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12/06/2001 20:48 5085647270 JOHN GRACI SEPTIC PAGE 08
Page 8 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: IS HOLIDAY LANE WEST HYANNISPORT,MA 02672
Owner: MR.SPIVAK
Date of Inspection: VVOI
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain):n/a
Dimensions: n/a
Capacity:n/a gallons
Design Flow:n/a gallons/day
Alarm present(yes or no): N/A
Alarm level:N/A Alarm in working order(yes or no):NO
Date of last pumping: n/a
Comments(condition of alarm and float switches,etc.):
n/a
DISTRIBUTION BOX:X(if present must be openedxlocate on site plan)
Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE
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.):
DISTRIBUTION BOX 1S BROKEN AND NEEDS TO BE REPLACED.
PUMP CHAMBER:_(locate on site plan)
Pumps in working order(yes or no): NO
Alarms in working order(yes or no):NO
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
n/a
A
f 12/06/2001 20:.48 5085647270 JOHN GRACI SEPTIC PAGE 07
Page I of l 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 18 HOLIDAY LANE WEST HYANNISPORT,MA 02672
Owner: MR.SPIVAK
Date of Inspection: 8/2/01
BUILDING SEWER(locate on site plan)
Depth below grade: 18"
Materials of construction:_cast iron _40 PVC Xother(explain):20 PVC
Distance from private water supply well or suction line:n/a
Comments(on condition of joints,venting,evidence of leakage,etc.):
TOWN WATER
SEPTIC TANK:X(locate on site plan)
Depth below grade: 12"
Material of construction: Xconcrete_metal fiberglass_polyethylene other(explain)n/a
If tank is metal list age:n/a Is age confirmed by a Certificate of Compliance(yes or no):NO(attach a copy of certificate)
Dimensions: I OW L 8'6"H 5'7"W 4' 10""
Sludge depth: 1"
Distance from top of sludge to bottom of outlet tee or baffle:33"
Scum thickness: 1"
Distance from top of scum to top of outlet tee or baffle:6"
Distance from bottom of scum to bottom of outlet tee or baffle: 17"
How were dimensions determined: MEASURED
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
THE SEPTIC TANK AND ALL COMPONENTS APPEAR TO BE STRUCTURALLY SOUND AND APPEAR TO
BE FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE
SYSTEM'S USEFUL LIFE,
GREASE TRAP:—(locate on site plan)
Depth below grade:n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain):n/a
Dimensions:n/a
Scum;thickness: n/a
Distance from top of scum to top of outlet tee or baffle:n/a
Distance from bottom of scum to bottom of outlet tee or baffle:n/a
Date of last pumping:n/a
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related
to outlet invert,evidence of leakage,etc.):
n/a
12/06/2001 20:48 5085647270 JOHN GRACI SEPTIC PAGE 06
Page 6 of 11
OFFICIAL INSPECTION
S TION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: I8 HOLIDAY LANE WEST HYANNISPORT,MA 02672
Owner: MR.SPIVAK
Date of Inspection: 8/2/01
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x 4 of bedrooms): 440
Number of current residents:2
Does residence have a garbage grinder(yes or no):YES
Is laundry on a separate sewage system(yes or no):NO (if yes separate inspection required]
Laundry system inspected(yes or no): NO
Seasonal use:(yes or no): NO
Water meter readings,if available(last 2 years usage(gpd)): n/a
Sump pump(yes or no):NO
Last date of occupancy: n/a
COMMERCIAVINDUSTRIAL
Type of establishment:n/9
Design flow(based on 310 CMR 15.203): n1agpd
Basis of design flow(seats/persons/sgft,etc.): We
Grease trap present(yes or no):NO
Industrial waste holding tank present(yes or no):NO
Non-sanitary waste discharged to the Title 5 system(yes or no):NO
Water meter readings,if available:n/a
Last date of occupancy/use: n/a
OTHER(describe): n/a
GENERAL INFORMATION
Pumping Records
Source of information: n/a
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: n/agallons--How was quantity pumped determined? e/a
Reason for pumping: n/a
TYPE OF SYSTEM
X 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):n/a
Approximate age of all components,date installed(if known)and source of information:
18 YEARS
Were sewage odors detected when arriving at the site(yes or no):NO
12/06/2001 20:48 5085647270 JOHN GRACI SEPTIC PAGE 05
Page S of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 18 HOLIDAY LANE WEST HYANNISPORT,MA 02672
Owner: MR.SPIVAK
Date of Inspection: 8/2/01
Check if the following have been done. You must indicate"yes" or"no"as to each of the following:
Yes No
X _ Pumping information was provided by the owner,occupant,or Board of Health
X Were any of the system components pumped out in the previous two weeks?
X Has the system received normal flows in the previous two week period'?
X Have large volumes of water been introduced to the system recently or as part of this inspection?
- X Were as built plants of the system obtained and examined?(If they were not available note as NIA)
X Was the facility or dwelling inspected for signs of sewage back up?
X _ Was the site inspected for signs of break out"
X _ Were all system components,excluding the SAS,located on site'?
X 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,?
X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance
of subsurface sewage disposal systems 2
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
- X Existing information.For example,a plan at the Board of Health.
X , 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))
12/06/2001 20:48 5085647270 JOHN GRACI SEPTIC PAGE 04
Page 4 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: l8 HOLIDAY LANE WEST HYANNISPORT,MA 02612
Owner: MR.SPIVAK
Date of Inspection: 812/01
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for alLinspections:
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged
SAS or cesspool
X Static liquid level in.the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool
X Liquid depth in cesspool is less than 6"below invert or available volume is less than './;a day flow
_ X Required pumping more than 4 times in the last year XW—due to clogged or obstructed pipe(s).Number of times
pumped nla.
- X Any portion of the SAS,cesspool or privy is below high ground water elevation.
_ X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool or privy is within a Zone 1 of a public well.
_ X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
- X 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 forma
(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. barge Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
X the system is within 400 feet of a surface drinking water supply
_ X the system is within 200 feet of a tributary to a surface drinking water supply
_ X the system is located in a nitrogen sensitive area(interim Wellhead Protection Area—1WPA)or a mapped
Zone Il 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.
a
i�
12/06/2001 20:48 5085647270 JOHN GRACI SEPTIC PAGE 03
• Page 3 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 18 HOLIDAY LANE WEST HYANNISPORT,MA 02672
Owner: MR.SPIVAK
Date of Inspection: 8/2/01
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.
I. 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 I 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 n/a
""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 flrorn 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:
o/a
Z
12/06/2001 20:48 5085647270 JOHN GRACI SEPTIC PAGE 02
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 18 HOLIDAY LANE WEST HYANNISPORT,MA 02672
Owner: MR.SPIVAK
Date of Inspection: 8/2/01
Inspection Summary: Cbeck 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:
THE SYSTEM CONDITIONALLY PASSES TITLE V INSPECITON.THE DISTRIBUTION BOX IS BROKEN AND
NEEDS TO BE REPLACED,
a. System Conditionally Passes:
X 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.
n/a 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:n/a
n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed
pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of
Health):
broken pipe(s)are replaced
_ obstruction is removed
_ distribution box is leveled or replaced
ND explain: n/a
n/a The system required pumping more than.4 times a year due to broken or obstructed pipe(s).The system will pass
inspection if(with approval of the Board of Health):
_broken pipe(s)are replaced
_obstruction is removed
ND explain:n/a
• ' `e COMMONWEALTH OF M4SSAC91:SETTS
EXECUTIVE OFFICE OF E\NiRO�NTE�TAL AFFAIRS 1
DEPARTMENT OF ENVIROSMENTAL PROTE IOC.' 2
..O V BE ,l%'TER STREET BOSTON AtA 02106 61:-.4=-�:0G
s
V�lLL1A�.:F.V,�LD
Cmv •;.:. y�OA 1 TAL'D.I�CrG?-
�nt:• :.
' r 4
ARGi:O PALL CEILI'CCI - - _ DA�ziD B S I Lam_
LL Governoi SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM^„ � 9 �C�omrrissiorr
PART A
CERTIFICATION
Property Addres;; 4 �''' qn " ' �s Address of Owner: fJ�u=lS
Date of Inspection: % - _ 411 difierent)
Name of Inspector. 14.,4 10 I 1 E��C�a - ' ' � `v'�1
1 am a DEP ap roved system i sn pector pursuant to Section 15.340 of Title 5 010 CMR 15.000) �Z.��2►
Company Name: a n A-,*0'rJ M 0-1 AA
Mailing Address: 'P e75 /;,=x e-375F CJ, - hr 1'C7 2-6-4-C7 .
Telephone Number: e-SC C6 5-2-- /4 o
r •
CERTIFICATION STATEMENT
I cert,f that I have pe•sonally ,r.spec:ed the sewvaze d:spasal syste- at this addres! and that the information rer;orted be-ow is true. accurate
and comolem as of the time of inspecion. The inspec::ori was pe-icrmed based on my training and experience in the proper func:lcr. and
maintenance cf on-site sewage disposa; !~•stems. The stern.:
Passe:
_ Conc:t,onaii\ Passe!
',eec; Funhe• Eva!uavo^ Ey the Local Approving Authcrm
_. Fa•'s
Inspector's Signature: Date:
qrJT�-,
T:ie SvS.en- Ins _o• sha" subm,; a copy of this inspeG:on re.-c- to the Aporovir,g Autherin. within thi r;ti. (301 days of completing this
inspection. It the system is a shared systern o• ha; a de_-gn flowof 10.000 gx or greater, the ,nspezor and the syste n owner Shall submit
the repo-: to the norocriate regional o^f.ce of the De;a-ment of E-ivirenmenta' Protecior.. The cr,g:na! should be sent to the systern c ne-
and copies :'-it to the buve-, it. applicable. and the aparoving authorin
INSPECTION SUMMARY: Check A, E, C, or D
Al 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 indicate--' below. .
COMMENTS:
BI SYSTEM CONDITIONALLY PAS5E5: -
One or more system components as described in the 'Conditional Pass' section need to be replaced or repaired. The system, upor.
completion of the replacernent or repair, as approved by the Board of Health, will pass.
Indicate yes, no, or not determined (Y, N. or NDi. Describe basis of determination in all instances. If'not determined', explain why not.
The septic tank is metal, unless the owner or operator his provided the system inspector with a copy of a Certificate of
Compliance (anached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or
the septic tank, whether or not metal, is cracked. structurally unsound, shows Substantial infiltntion or exfiltration, or tvnk
failure is imminent. The system will pass inspe^.ion if the existing septic tank is replaced with a conforming septic mnk
w approved by the Board of Health,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A '
CERTIFICATION (continued) ,
Property Addms:
Owner: '
Date of Inspection:
Bl SYSTEM CONDITIONALLY PASSES tcon"J'Pd »
` Seware backup or breakout or high static water level observed in the distribution:box is due to broken or obstructed
pipe:sl or due to a broken, settled ar uneven distribution box. The system willpass inspection if(with approval of the
'`Board of Healthl. Describe observations: _
brokers pipe(s) are replaced .
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipCsl.:The system will pass
Inspection if twith approval of the Board of Health):
broken pipets; are replaced
obstructtor. is removed r.
CJ FURTHER EVALUATION 15 REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which ret:uire furthe• evaluation by the•"Baard of Health in order to determine if the iystern is failing to prates the
public health• saie-v and the environment.
Y T M W1 PASS UNLESS BOARD OF HEALTH DEIMLAiNE5 THAT THE SYSTEM 15 NOT FUNCTIONING IN A MANNER
1) SSE ll _
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFE,SY AND THE ENVIRONMENT:
Cesspool or prnti Is within 50 fe--:�of a surface water
Cesspool ar pna• is within 30 of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOXRO OF HF-.kLTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIOti11G'I MAtitiER THAT PROTECTS THE PUBLIC HEALTH AND SAFtiY AtiD THE
ENVIRONMENT:
The sysern has a septrc tank and sail absorption system (Sj and the SAS is within 100 fee: to a surface water supply ar
tnbutarn• to a surface water supply.
_ The system has a septic tank and sail absorption systern and the SAS is within a Zone I of a public water supnry well.
The syste-n has aseptic tank and sail absorption system and the SAS is within 50 fee: of a private water supply well.
The syste-n has,a septic tank and sail absorption systern and the SAS is less than. 100 fee: but 50 fee: or more from a
private water supply well, uniess a well water analysis for coliform bacteria and volatile organic compounds indicate, tha
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. Method used to determine distance (approximation not valid).
3) _ OTHER /
(revised 04.23/9'1 Page 2 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Addr-ss:
Owner: r�
r
Date of Inspection:
D] SYSTEM FAILS:
You must indicate either 'Yes" or "No' as to each of the following:
I have determined that the system violates one or more of the following failure criteria w defined in 310 CMR 13.303. The casts
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
i
Yes No
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due town overloaded or clogged SAS or
cesspool.
Static !jauid level in the distribution boa above outlet invert due to an`over)oaded or clogged SqS or cesspoo!.
rr
Liauid depth in ce<spool is less than 6• below invert or available volume is less than ,1/2 day flov.
f
Reouired pumping more than 4 times in the last year NOT dueao clogged or obstructea pipe s .
Number o'times pumped _
An%- portion o'the So:l Absorption Svstem, cesspool or phyl• is below the high groundwate• eievatjo-
Am. por:on o'a cesspool or privyis wither. 100 feet of ar'surface water supply or tributar to a surface water supple
Any porion of a cesspoo' or prnv is w rlhrr a Zone 1,of a public well.
3
/
An% pc-.ion c-a cesspool or prt\,1• is within 50 feet`of a private water supply well
Am• por.or. o'a cesspool or privy is less than 1-b0 feet but greater than 50 feet from a private water supply well with no
acceotable Ovate, qualm analysts. It the well.Yeas been analyzed to be acceatabie. artach cop%- of well water analysis for
cohiorm bacteria volatile organic compou�s, ammonia nitrogen and nitrate nitrogen.
EJ LARGE SYSTEM FAILS:
You must indicate either -Yes` or "No" as to each of the)
he f llowing.
The following criteria aPp;% to .arge systems infaddition to the criteria above:
The system serves a facility with a design fl/of 10,000 gpd or greater (Large System; and the system is a significant threat to
public health and safes and the environm nc because one or more of the following conditions exist.
Yes No .
the system is within 400 f"-t of a surface drinking water supply
the.system is within 200 eet of a tributary to a surface drinking water supph -
the system is located i a nitrogen 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 sy tem shall bring the system and facility into full compliance with the groundwater.treatment program j
requirements-of 314 CMR_5.00 and.b.00. Please consult the local regional office of the Department for_furthe.r.informat.ioct:--- - - --- - -- --
(revised 04/75/91) Page 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Addcess: �j t�lld
Owner:
Date of Inspection:
Check if the following have been done: You must indicate either "Yes" or "No' as to each of the following:
Yes
Pumping information was provided by the owner, occupant, or Board of Health.
_ None of the system components have been pumped for at least two weeks and the system has been receiving 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 built plans have been obtained and exammed. Note if they are not available with N,A.
The or d%%ellmg was inspected fo, signs o-*sewage back-up.
_ The system does not receive non-sanitan• or industrial waste flow.
The site %%as inspected for signs of breakout.
f _ All s\sterr. co^tponent_. excluding the Soil Absorption System, have been located on the site.
L _ The septic tank manho;es Here uncovered. opener'. and the interior of the septic tank was inspected for condition of
baffies or tees. materta'. o'construction. dimensions, deptn of liquid, depth of sludge• depth of scum.
The size and location of the Soil Absorption Svstem on the site has been determined based on.
The fac-lic, o\%ne• ,anc occupants. if drfteren: from ow•neri were provided with information on the prope, maintenance of
Sub-Surface Disposal Svsterr..
Ex:stmg information. Ex Plan at B.O H.
Determined in (ne field +c an, of the failure'criteria related to Part C is at issue, approximation of distance is
unacceptable 115.302.3t:b1!
(ro�iaad 04/25/511 Pago 4 of 10
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR.tit
PART C
rp SYSTEM INFORMATION
Propern Address: 1T Act,\
Owner: 6t3w S •
Date of I spection:
\ FLOW CONDITIONS
RESIDENTIAL:
Design floe. J40 D.cllbedroorn for SAS
Number of bedroomsed
Number o:current.reside ts•_
Garbage g•::der (yes or no.,: HIPS-
.Laundry cor—ected to system (yes or no'-
Seasonal use (yes or no!:
Water meter readings. if available (last two ;21 year usage tgp& ti
Sump Pump (ves or note
Lai. da:e or occupancy- t-Apr
COMMERC i 4,0 N DL'STR I AL:
Type of establishment
Design fio%% _gal,onslda%
Grease trap present Ives or no_
Induvr,a! %%aste holding Tani: oresen;. eves or no_
':on-sari,ta,% -Aaste d,scnargec to the T!:,e 3 sys:ern ;ves or no
%%ater meter readings if availabie
Las:Pate o; o .:.;a,1c,
OTHER; Describe
Last sate of occuoanc.
GENERAL INFORMATION
PUMPING RECORDS and'source of inior .at,or.
System pumped as par, of inspection: wes or no.L?e
If yes, volume pumped eallons
Reason for pumping
TYPE,QF SYSTEM
Septic tank./distribution box.'so,l absorption system
Single cesspool
Overflow cesspool
Prn)
Shared system (yes or not (if yes, atsach previous inspection records, if any) _._.-.
I/A Technologv etc. Copy of up to date contract?
Other -
APPROXIMATE AGE of all components, date installed (if known) and source of information:
Sewage odors detected when arriving at the site. (yes or not
(revised 04/25/91) Page 5 of 10
1
SL:BSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORPA
PART C
(, tt SYSTE.NA INFORMATION (continued)
Property Address:
Owner: C. ( J
Date of Inipe tia4
BUILDING SEWER:
, ictalLe on site planl
Depth below grade.. .
Material of construction. _cast iron _40.PVC _other (explain!
;,-,nce from private water supply well or suction Ire
Diameter
Comments: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK:IS
(locate on site p a.n
Depth below grade
material of construction: y concrete —me-,a _,Fioerg,ass _Polyethylene _othertexplain
'ink is metal. Its: age — Is age coniirmec'o� Ce-,.6ca:e o: Compliance
Dimensions 111on Cie,
Sludge depth tt
%.,isiance from top o: s:uoge to bonon o` ou:ie: tee o• bade JI
Scum thickness-_fP _ fl
Distance from top o' scum to top of outlet tee or bake _ I�
Distance iron+•+ bonorn o scum to bono-^ o� outlet tee e• bar•.e
How dimensions were determined ltl.ld r
i Comments
m,commendation for pumping. condition o!' inl and outlet tees or baffles. depth of liquid level in relation to outleA invert. stru r •�
integriry evidence of leakage. e:c.i 4- d
l
GREASE TRAP:
(locate on site pl n.
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: -
"omments: ==
;ommendation for pumping. condition of i•,let and outlet tees or baffles. depth of liquid level in relation-t"utlet4nvem. structural -- -
.rgrtty, evidence of leakage. etc.;
.d 14111,*111 Page 6 of 10
f
lk7-
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Propertm Address:'I�
O%ner:%v, �5
Date of pection: r)I.
TIGHT OR HOLDING TANK:,.-rank must be pumped prior to, or at time, of inspect)oni
(locate on site plan,
Depth below grade.
Material of construction. _concrete _metal _Fiberglass _Polyethylene —other(explain)
Dimensions:
Capacuy gallons
Design flog gallons.da,
Alarm level A:arm in N:ork:ng orde• _ Yes. No
Date of previous pumping
Comments
(condition of inlet tee. conditior o- a!a,rr. and float switches. etc.)
DISTRIBUTION BOX: &
tlocace on site p:a-
De�-:h o-' liouid le e' a00%e outle: in�e- r v4ou ,F Pr-'V T-
Comments
mote :i leve! and dis;rib Uor, is aua. evidence of solids carry •er, evict nce of leakage into or out of boa, etc.)
St. t S VZ �' K,
t
PUMP CHAMBER: Coo
(locate on site plan
Pumps in working order: (Yes or No,
Alarms in working order (tes or No.
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 04/15!97) Page 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Addr-`is:
Owner: � NEJ
Date of InSpecuon: ,
SOIL ABSORPTION SYSTEM (SAS):
(locate on site plan, ti possible: exca�a,�on not required. but may be approximated by non-intrusive methods
If not determined to be present, explain:
Type
leaching pits. number.`�x
leaching chambers, number:_
leaching galleries, number.
leaching trenches, number,tength:
leaching fields, number, d.rnensjo.n.s
overflow cesspool, number
Alternative system
Name of Tecnnotogv
Comments
mote cond'tion,of S it', signs of hydraulic fa I re, leve'i of ponding. condit' of getation, etc.'
i
CESSPOOLS:
(locate on site plar.
Numbe, and conf,gura:,on
Depth-top of liquid to inlet Inver,
Depth of solids Jaye-
Depth of scum layer.
Dimensions of cesspool
materials of construction
Indication of groundwate-
inflow tcesspool must oe pumpec as par, of tnspenor'
Comments:
Incite 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.):
(revised Page 3 of 10 .
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
r� SYSTEM INFORMATION (continued
Propert,, Address: N �ftd0
Owner. gau""'LS
Date of Ir„pection:�( ��c
SKETCH OF SEWAGE DISPOSAL SYSTEM.
include ties to at least two permanent reierences landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
r
F 12e tj A
..r
35
tr•vla•d 04125!57) P•q• ! of 10
~ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
R
PART C
SYSTEM INFORMATION (continued)
Propert% Addres-• L4,1
Owner: ��tr�
Date of In§pection:
"ll 1
t �
Depth to Groundwater- � Feet
I to determine High Groundwater Elevation:
Please md�cate all the methods used g
Obtained from Design Plans on record
Observation o-*Site (Abuning property-, observation hole, basement sump etc.)
Determine it irom local conditions
Cnec" %%ah local E3arc c• yea :r
Chec�. FENAA macs
Check p-i'nping records
Checl local exca�-xo•s irs:alle•s
L se S_: Da:a
r•
Describe 11 %c j, o"- ,•xc: rc,., %o_ es:ao;:!hec the :g`. Crounc"ate• Elevation (Must be compie:ec
raj tAOJT f qi W. ��- (T 1 tv'
trwlee•a. :�.':S '9- Page 10 of 10
eT'J THE COMMONWEALTH OF MASSACHUSETTS
` �-_.::-.B_OARD OF HEALTH
\ 15�. .... ......OF.........� 2. /�.T I�_ t --------------------------
Appliratiun for Uiupuual Works Tomitrnrtiun ramit
Application is hereby made for a Permit to -Construct (,Y) or Repair ( ) an Individual Sewage Disposal
System at:
...........ze.-r...........................................................................
Locatio Address or Lot No.
•.�. ............. ........•---.�---•-•-.... ..........
�� o�c+ /
...................•- � ...
ress
dType of Building Size .....Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic (,X) Garbage Grinder ( )
Other—T e of Building ......... No. of persons............................ Showers — Cafeteria
dOther fixtures ---------------------------------T�.�D26orn
W Design Flow........../?U........................gallons per-pgrsen per day. Total daily flow................... . ---------gallons.
WSeptic Tank—Liquid capacity,/_�RgalIons Length./] .L0... Width,-_.'�_.o..... Diameter................ Depth..,5_.'- .'"
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area_._.....•......_..__sq. ft.
Seepage Pit No..................... Diameter.....1_(:2_.-: Depth bGowpe' ___��. .. Total leaclyin�G _..3. sq. ft.
Z Other Distribution box (X) Dosing tank ( ) �41 OPercolation Test Results Performed by....Z.41_._.....• ...................................... Date----��...�-_9.........
Test Pit No. 1. .._..minutes per inch Depth of Test Pit.__./. .__ Depth to ground water........................
Test Pit No. 2--- �...minutes per inch Depth of Test Pit.._./ram 1`'__. Depth to ground water________________________
�+ ••--•---•----•------------•-------•••.......----•--•-••- ....--•----•-•--•---•.............•_..............................................................
Description of Soil� - �4Q.t7� �9! ?y........ - �1� ...5%en.! x.-5. a.1-k-f------ ------------
v ..3 ...........� .._... %Lr9_r�.._.. v�._._ '/� -------------- /_.. ?- rh'_
W •••----•-••----------------•-----••---------------------•-•-----------•-------•-••-••••---•--•-•••----••----•------------------•-----•----•--•-•-••--•-•••--•-•••---------------••--•---•-----•-•--•...
VNature of Repairs or Alterations—Answer when applicable...............................................................................................
---------------------------------------------------
•-------------------------------
----------------------------------------------
•--•---------------------------------------------------
................
Agreement:
The undersigned agrees to install the aforedescri ed Individual Sewage Disposal System in accordance with
the provisions of TLI'il.E 5 of the State Sanitary Cod —The undersigned furt agrees not to place the system in
operation until a Certificate of Compliance has e ' sue -y the board of h t .
Sigd -• -- ....... •• "/--------------------------- ...�� / ... ,9
Application Approved BY
Date
Application Disapproved for the following reasons:-------•---------•--•-••----------------•---------------------•--------------------•-•-•---------•............�
......•-----------------•-•-••----•-•----•---•--•-••--------•---•------••-•-----------------------.....----••••-•---•----•-••-•••-•----------•-•---•------------•-•....................................
Date
PermitNo..................................................._.... Issued......-•--....... •...........:.......
Date
No........... .... FEz............._..............
THE COMMONWEALTH OF MASSACHUSETTS r
BOARD OF HEALTH
' V.w 3 L• i`
/... .KID.--.........OF......../3. 19..21/rr/...73 C, /�
F
Appliration for Disposal Works Tnnitrnrtinn amit
t Application is hereby•made for a Permit to Construct ( k) or Repair ( ) an Individual Sewage Disposal
System at
Location Address or Lot No.
.............. d.-.:: .._.....___.__.Y.. y _.-_.__.-•.________ ..........__._..___...____............_-_•••. ...............................................
�� Address.
W
/ S' e ....... feet
Dwelling—No. of Bedrooms..........Z........::....................Expansion Attic (re ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
p" Other fixtures .................................
/G & r 0-------------------------------------------....__...------ --------•...._.---------•-----------
W Design Flow..................•............_....._..__..gallons per 4wzsen per day. Total daily flow..._.._....•-_...�f.__�-�_...U...........gallons.
WSeptic Tank—Liquid capacity/Z gallons Length.//-'�'_O.. Width-�6_.... Diameter................ Depth..0.'—Z.?
x Disposal Trench—No. ................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No._.._.._Z Diameter.................... Depth Belo i et._ q.T.... Total lea,, I a ` s ft.
z Other Distribution box (.k)': Dosing tank
Percolation Test Results Performed by......R...:_.�....... .............. �?:.--.............-`. Date_....31?1 ............
Test Pit No. I....�_ ..minutes per inch Depth of Test Pit._.,. .'. Depth. to ground water-------_____..__-----__.
(s, Test Pit No. 2.__G.Z.'.minutes per inch Depth of Test,.Pit.. Depth to ground,,water............ .:...... ,
xDescription of Soil_a.� Wl . i a ......... G �9 ....... ,F = `-----•-----•-•-----
U ?eFP..... .hln...........�5-t- .._z.......S.----•- .........
(xa
UNature of Repairs or Alterations—Answer when applicable...............................................................................................
s
Agreement:
The undersigned agrees to install the aforedescribed Individual"'Sewage Disposal System in accordance with
the provisions of TITL is 5 of the State Sanitary CodeThe undersigned further agrees not to place the system in
operation until at Certificate of Compliance has been iss4d by the board of health.
3 �1
gne 4 A ` .....___. D.
Application Approved BY--------------/, r..... . ......... .... .. Dator
Application Disapproved for the following reasons:;..........................................
..._..._
r;
Date
PermitNo...................................--••-••-•-•------•.. J'Al Issued--•--------------••-•-•------ •---.....---•-------
Date THE COMMONWEALTH OFWASSACHU+DETTS
BOARD -Of :HEALTH
.................. rl �. OF.....
(grrtif r�dr of unto 1 Art
THIS IS TO ERTI Y That the Individual Sewage Disposal System•construc.ted-,( ) or Repaired ( )
by...........................
{
✓� In P�
r
has been installed in accordance with the provisions` of TITX..
5 gf State Sanitary Code as.described in the .
application for Disposal Works Construction Permit No....... . .. ......... da.tedr., �� �:_ 7_ t.._..........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE gONSTRUED AS A GUARANTEE THAT YHE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.... . �................: ................. Inspector.. ._ .....x: h � --•-----...----•----
THE COMMONWEALTH OF MASSACHUSETTS
BQARD HEALfH
............... ..........OF....... +' '�?'. ...............................
No.......... ...... FEE..... ........
IIAL
Permission is hereby granted.."..-, --- •. ... .. .... •=-
to Construct' Rep r ( ) an I I al Se a posal S tern
at No .. '
.. , . : y.
iiS'� -•---
as shown on the.application for Disposal Works`Construction Pe 4. Igo:-_ /_._:Dated..3./ .....F..........
.>, r Board ►.....-
'.._.._..�
DATE.. 5� -•----• -•-•--
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
. vWl
io
SfJI
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w.a rz ��a Asp
t� �
a I-
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RICHARD s DAMES
s ? DAMES Q'HEARN n
o p`HEARN 691
list `
LEGEND
pyO Q/8 f 6 SANITa4�R
y EXISTING .`SPOT . El_£1'ATiOFSS O,A $VIR
`EXISTING _: CONTOUR - 0
*S OA
= FINISHE.D _ POT ELEVATION.$ D
' FINISHEfj C,ON I OUR 0 -
PROPOSEa. .:PLOT PL ►h1 r'
APPR^'OVER. BOARD--. of HEALTH �,�1��VS.Tr�13L� MA Ss
--L
_.AGENT oTa1�vY
` I CERTIFY . THAT THE :: PROPOSED, .' f�' . ✓ O HEAR/1/, INC, /,-LS, r?31
Bl3ILDt,��-G S`HOY1':N ON . THIS :PLAN I3�i8 r�OUTE t34
CONFORMS . TO : THE., ZONING LAWS. :;
EAST - DE.tvNIS,'MASS;
^ OF,!'9. s��i3/- MASS. DACE
JOB. N0. Z-� _ CLIENT = `J�c. s� s✓ '^
_ 1`NVE�RT,: .ELEVAT�IONS
NOTES=
S01L: TEST ,u
_ 3 ALL WORKMANSHIP ` AND_ MATERIALS
DATE : OF- SOIL ..TEST 319%9 INVERT AT BUILDI-NG. _2_ FT
WITNESSED BY %�
.�. r ;a INLET 'SEPTIC`, TANK .. F,T.- SHALL ,CONFOR.M TO' D.EC E TiTLE
F B,¢ lrsr,4RUL:ES`:
T L OUTLET"-,SE, TANK , 92- FT AND_ THE TOWN. 0 ,
PERCOt' T.ION .RATE z MIN./INCH
92, o FT AND REGULATIONS � FOR SUBS.U'RFAC.E
OBSE ATION .HOL.E L . OBSERVATION` HOLE : 2
INLET DIS.TR�I:BUTlON.. BOX
RV, si..A DISPOSAL OF ,SANITARY SEWAGE
ELEVATION, ELE -
,; OUTLET DISTRJBUT1ON BOX: FT
—:.. `.INLE.T , LEACHING;: PI:T � FT:
� - ,.
EACHING P -T FT.
BOTTOM� L i �
r
1,
,
DES CALCULATIO NS
NUMBER OF BEDRQOMS:.
Y Y
GARBAGE:� DISPOSAL 'y UNIT... wo �
c� TOTAL :"ESTI°MATE`D' FLOW (// GAL./BR /DAY'x�. BR.),.. GAL./DAY
elf c 0 H,Ep. 6 4-2—.
SEPTIC " TANK CAPACITY. ....,. _ GAL. -
REQUIRED-
I SU GAL.
• ACTUAL SIZE OF` SEPTIC TANK TO BE INSTALLED... . /2
: LEACHING AREA, REQUIREMENTS. .
/yy
.:SIDE
_WALL: AREA 2•SGAL./S'F ,
.BOTTOM AREA A - .
L SIDEWALL )...... . . . /099 GAL.
E 1�.Q G L /S F.
3lN��s- PYf-3BO x.10 xz• S) 9 F:
EAC
. . . . . . . .
z �0 9
ES RVE LEACHING'. CAPACITY. . . .
zGl
. ,: • , GAL.
TOP OF
FOUND.
ELEV.= 9� d �a ��. M,;✓ CONCRETE 4�" SCH 4O. CLEAN SAND
COVERS PVC PIPE
f
:MLN� PITCH CONCRETE
I/8 PER-. FT,:.,
- _ 2% MIN. PITCH ` 114 OFMgs
3 f 12 MAX. - `h T4.ft'y� y0� RlCHARD
� o� yG
Z. F .I�S -L/2 RlCHARDES
FLOW" LINE:. ` . 2; .LAYER 0 VHEARN
o
- WASHED STONE
4�� CAST IRON c�STC {p
A E
PIP - MIN.'- PITCH : o; o W moo:' H ST V£
3/4 i I/2
E WASHED ED STONE
UR
SAN
1/4" PER FT, DST.
BOX , w . a;o BASIN:PRECAST.
OR-. EQU V.LEACHING
�. r.vy
/2sd GAL
v
MA
SS
M -
r . BE T
J. Q'HEARN,-I�NC.;_RLS � RS
-TAN:K ��-
<✓. T 4 ROUT ,_ -I34
I.�. MASS. ,
u
F7,
EAST DENN ,
'PROFILE:, OF. 4
:G.RQUND_: WATER TABLE
F .
SEWAGE DISPOSAL. SYSTEM _
Yi
CL.I EN
ti.. DgTE 3 iz SHEET:?'
_
NOT TO :SCALE 9
.
~
:.w. '.:. ..,. ...-.. .c. r.e+ r.....- �:...•_.r ... -1 r.r... , :. ...: S.:a S4 Zlj.