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HomeMy WebLinkAbout0019 IRVING AVENUE - Health 19 Irving,Avenue;-; i Hyannis- P A = 286 006 i j e 1 C�����,7,yf,TOWN OF BARNSTABLE Q Mll a l e LOCATION ' , SEWAGE # 6/179 7 VILLAGE ASSESSOR'S MAP & LOT Q� INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY ,�®® LEACHING FACILITY:(type) �L. � ,(size) ®�0 NO. OF BEDROOMS_ R PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: / DATE COMPLIANCE ISSUED: VARIANCE GRANTED: MW a s P COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS >� DEPARTMENT OF ENVIRONMENTAL PROTECTION MAP r PARCEL ; DOG - LOT TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:. Owner's Name: Q Owner's Address: A l Date of Inspection: RECEIVED Name of Inspectftplearint) �� �Dl � '/ MAR 0 5 Z004Company NameMailing Address TOWHEALTH DEPTAB� Telephone Number: -`7 /- CERTIFICATION STATEMENT I certify that 1 have personally-inspected the sewage disposal syst6in 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 t 1 Inspector's Signature: 7 -k� Date: /�lr o The system inspector shall submit a-copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10.000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. .Notes and Comments- +' ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page I Page 2 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspec ion: Inspection.Summary: Check A,B,C,D or E/ALWAYS complete all of Section D. A. ystem Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15303 or`in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes:. One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration.or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: ObseNation'of sewage backup or break out or high static water level in the distribution box due to broken or. obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with. approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more.than'4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health):. broken pipe(s)are replaced obstruction is removed ND explain: 2 r , Page 3 of 1'l OFFICIAL INSPECTION FORM.- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: WA f dW Up)� ',b Date of Inspect on:— C. Further Evaluation is Required by the Board of Health: . Conditions exist which requite further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance **This system passes if the well water analysis, performed at a DEP certified laboratory.for coli.form bacteria'and volatile or'aanic 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: 3 Page 4 of 1 I OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART A CERTIFICATION(continued) Property Address: 19-,JjW1Xz Owner: Date of Inspection: Jr- Sl D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes N �. Backup of sewage into facility or system component due to overloaded or clogged SAS or cessp'ooi 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 'h day flow V 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. Any portion of a cesspool or privy is within a Zone l'of a public well. " _ Any portion of a cesspool or privy is within 50 feet of a private water supply well. j/ 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 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. f E. Large Systems: To be considered a.large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gPd• You must indicate either"yes"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 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 4 Paae 5 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE,SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECIMST Property Address: �Q QOwner: _ Date of Inspect on: 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 t"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 ? _ZHave 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) V 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:. Yes no _✓ Existing information. For example, a plan.at the Board of Health. Determined in the field any of the failure criteria related to Part C is at issue approximation of distance ( Y is unacceptable) [310 CMR 15.302(3)(b)] t 5 Page 6 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS $, SUIMR.I+ACE SEWAGE DISPOSAL SYSTEIVLINSI'ECTION rOR1VI PART C SYSTEM INFORMATION- Property Address: 191�'"_ALe n?/ Owner: Date of Inspecti n:ZJ" , FLOW CONDITIONS RESIDENTIAL ✓ Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 11.0 gpd x#of bedrooms): Number of current residents: . Does residence.have a garbage grinder(yes orno.)�: �-�- Is laundry on a separate sewage system (yes or no if yes separate inspection required] Laundry system inspected es or no2 Seasonal use: (yes or no. Water meter readings; if av Table(last 2 years usage(gpd)): 02- ZL,�D� 0.3 Sump pump(yes or no): Last date of occupancy: COMMERCIAL/INDUSTRIAL///L6- Type of establishment: Design flow(based on 310 CMR 15.203). gpd Basis of design flow(seats✓persons/sgft,etc.): .. Grease trap present(yes or no):_ Industrial waste bolding tank present(yes or no): Non-sanitary waste discharged to the Title,-5 system(yes or no):_ Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records - Source of information: Was system pumped as4p'artoe i specti (yes or no): If yes,volume pumped: _ gallons bHow,was quantity pumped deterrnined? _ ''Reason for'pumping: TYP OF SYSTEM OF 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) i —Tight tank _Attach a copy of the DEP.approval —Other(describe): roximate age of all.eomponents date i tal ed(if known}and source of information: Were sewage odors detected when arriving at the site(yes or no)✓�� 6 Paee 7 of I 1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL; SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: N • . "A Owner:Vn _ Date of Inspect'on: �Sr aQ� BUILDING SEWER(locate on site plan)�� Depth below wade: Materials of construction:icast iron . 40 PVC _other(explain):,= _ Distance fiom 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 grad A- Material � Material of construction: L,—foncrete_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: (�•� �.�� 2(5 Sludge depth: 7l is r (A a Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness:f Distance from top of scum to top of outlet tee or baffle: `— Distance from bottom of scum to bottom f outlet tee or baffle: How were dimensions determined: P AJA ' Comments(on pumping recommen0 � ations; nlet and outlet tee or baffle condition; structural integrity, liquid levels related to outlet invert, evid nce of leakage, tc.): �e LXJ`CJ� GREASE TRAPf(/9--(locate on site plan) (l (7 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 condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 7 Page 8 of 11 OFFICIAL INSPECTION.FORM.—NOT FOR.VOLUNTARY ASSESSMENTS 'SUBSURFACE"SEWAGE-DISPOSAL SYSTEM,INSPECTION FORM PART C; SYSTEM.INFORMATION:.(continued) .. Property Address:1qj'1?jqJZt� e Owner: Date of Inspecti n: i,)My TIGHT or HOLDING TANK:/2 (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions'. Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches, etc.): DISTRIBUTION BOX: of present must be opened)(locate on site•.plan) . Depth of liquid`level'above outlet invert:, nvert ". Comments(note if box is level and distribution,to outle equal, any evidence bf solids carryover, any evidence of kage into r ou of box, e ): 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~appurienances;etc.): 8 Page 9 of 1 1 OFFICIAL INSPECTION )FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Avalyllv /ya AAA la Owner: Date of Inspecti n: 5 SOIL AiBSORPTION SYSTEM (SAS): !/locate on site plan, excavation not,required) If SAS not located explain why: Type ✓ 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, CESSPOOL(cesspool must be pumped as part of inspect ion)(]ocate on site plan) Number and confieuration: 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.): PRIVX.�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.): 9 Page 10 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS ' SUBSURFACE SEWAGE`DISPOSAL SYSTEM INSPECTION FORM _ ,.... PART C SYSTEM INFORMATION,(continued) Property dress ,d , lkl- �L,.Plyp—o Owner: ' Date of Ins � V 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. �1 /0 BCD�(O l f �y 10 Paae I 1 of II OFFICIAL INSPECTION"FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 'PART C 'SYSTEM INFORMATION (continued) Property A ess: � Owner: Date of Lispecti n:�� S ) SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to around water 1 Z 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(abuttincy g 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: �Z7 _ I 11 Permit Number: Date: Completed.by: HIGH GROUNDWATER LEVEL COMPUTATION Site Location: 7 �9�� i Lot No. Owner: �e� l�/�b�`!,�'/^LJ/5 Address: Contractor: /7/j�'j© C�J75j� Address: q!i Notes: &/I/'S STEP 1 Measure depth to water table tonearest 1/10 ft. .................... ......................................................... .Date month/day/year STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: OA Appropriate index well..............................�v4.f. .... OWater-level range zone .....................................................L� STEP 3 Using monthly report "Current Water Resources Conditions" determine current depth io water level for index well ........................... — month/year STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A), current depth to water level for index well (STEP 3), and water-level zone (STEP 213) determine water-level adjustment .......................................................................................... Cl'� STEP 5 Estimate depth to high water by subtracting the water- level adjustment (STEP 4.) from measured depth to water level at site (STEP 1) ........... Figure 13,--Reproducible computation form. 15 f _--- . . :� ���; �� n � `.��� ••�'7 �v 1 d � `__ _ � t 7 - I � , ! � . t. � ' ( s s f' � � i t i� `• . . Q �� �,;, ham. 4 I �� j� 1--� E A 4� i ja �? f �. J �. . � • to �s �. . � • � �• .� �� .. � :� � � = ' � �. if i � ���: . � � �w, a �� ���`_ �� _� � �_ } �� ' � z ----_._ ii �� {^ .., �(w . s�j No....T �..1._ Fps.. .J ........ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......��Y�'�1...............OF............... ����.. ......................... Appliratiun for Uigpuual Works Tonutrurtiun trrmit Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal system at: ..:Lar:-GP ti.J.PV > f. - • 1�1�1.c �- 1 ....................... ...................... .................... .Location- dd ss or Lot No. ..... .....................................................-----•----......................._._..... Owner Address a .........--•.........................................••••--...........•..................._....... ...............••........ Installer Address Type of Building Size Lot.... lit .........Sq. feet aDwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................. Showers ( ') — Cafeteria ( ) QOther fixtures ..•-•.....•---•-...•-••-•-•-•-•••.........................................._...•----••-•-..........................---•-•...........•-•-•............. Design Flow.............././"0..........�..,.�p.�gallons per person per day. Total daily flow.................. ...........gallons Septic Tank—Liquid capacity.74�Vg'allons Length......& Width:..,�./.Q.. Diameter... '.. Depth.. .... x Disposal Trench—No. .................... Width.._.::.r........... Total Length.::............... Total leaching area....................sq. ft. 3 Seepage Pit No.....4901t;... Diameter.......1Q..... Depth below inlet......-0.-.-.-.. Total leaching area..7 sq. ft. .......... Z Other Distribution box (/J . Dosing tank ( ) 1.4 Percolation,Test Results Performed by•••--••••......................•-•----...............................--.. Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ fZd Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ........................................................................................................................................... 0 Description of Soil.................................•-••-•--•-------.........-----•---......-•---------------------------------..........---•-•---.............................--•------••- UW •-----••..............•••-•-•-•••••-•---••••-•-••-......-••........:......---•-•--•----••-----•-••.......••••--••-•......................••--••......-•..................... Nature of Repairs or Alterations—Answer when applicable............................................................................................... --------••--------------------------------------•----------------------..........•-•-••-----•.......-•-•••••--••••••---••-•--••--•-•....••........---••----••••••••••••••••••-•-••....••---............. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of LITLZ 5 of the State Sanitary Code— The undersigned further agrees not to plate the system in operation until a Certificate of Compliance has been issued y the bo d f li Signed....... ...... .................. .......................... Application Approved By......... ... !?.. �' ate .....�....... ............................................ .... ................. � Date Application Disapproved for the f ollo�✓ing� reasons: ......................... .........._.. Date PermitNo......................................................... Issued....................................................... Date No.... - ----, - Fas .......-...._ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .... ............OF.......... I A its L aL ................. Appliration for Dispasal Works Tonotrnrtiutt 11rrtuit Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal System at: --• ,ti..r lrf�1/T �1 � !..._��_ �:.. .........-•-- ......................................... • = Location-Address or Lot No. ................................... ........................................... --..........---............................... Owner Address Installer Address �,��jj Type of Building ,`C Size Lot.__ ' ` r Sq. feet �-. Dwelling—No: of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) 4 Other—Type T e of Building No. of persons............................ Showers W YP g ..................•--•-•---• P ( ) — Cafeteria ( ) at Other fixtures ............................ WWDesign Flow...............11 _._.____.__........gallons per person per day. Total daily flow............. _ U..._......_galIons. WSeptic Tank—Liquid�capacitylq gallons Length__.R.�4'?.". Width:.. -'�.-6Q'eDiameter_...r�""._. Depth..`./- r. x Disposal Trench—No.I.................... Width.......i........... Total Length.................... Total leaching area....................sq. ft. ^ Seepage Pit No....4?&t�... Diameter.......f�- .......De Depth below inlet.....�0... 'f 7 ft. 3 P� P ..... Total leaching area..................sq. Z Other Distribution box O Dosing tank ( ) aPercolation Test Results Performed by.............•••••-••-••••-••----.....•-••--••-•----•••--•---•-•.......... Date........................................ 4 Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ fir Test Pit No. 2.............:.minutes per inch Depth of Test Pit.................... Depth to-groundawater........................ ---------•-••-----•----............. ...... ......... ...•-•-- ...... ODescription of Soil....................................................................................--•-•--------•--------•----.........----......------.....................••........ `. U ------------------ -------------- ------------------------------------ ............. ........-...--.----------------•-- -.-•••-•------------- ------ .... ........................... 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 TITLZ 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been isssuued b�the board of heaalth. Signed. .�''.:�.... :....rF.— C :....... ...... .......... .Date Application Approved By.. �1/1r....... -. .n^� �-- '� �� ••-•-•-•••--•......................... Date Application Disapproved for the f ollo'ng reasons:.............:. .� ...........•-••••••••••..............•••.......... -------•-•......... .--••••-•-••-•--•---•... ........-----••--------•••----•-•----...... ....--•--............-• - ........... Date PermitNo......................................................... Issued.......... ............................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Trrtif iratr of fauutplitturr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by.....................N..••--.........................----.........--••-•.............-•••------..................:......................----•--•-•--..:.--•--•.......................,............. n ,Installer at......:?��...--•..�.........r......,�. .. has been installed in accordance with the provisions odTITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No...k `1 .................. dated........ ..................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. ` DATE............ 1 1.. .. ?.: ........--•--••----•-••-.......... Inspector-_ -v ..� i` lr , n e..:.«. �v r••n w 4 f a•.a•a.a...uwsw.[:w..e...a u.-F..nx... ate a w N •#n t ..r.ew.w wtl n w.e.m•. v.0 wm a....s.. ....,..,....a ✓.. ..ro r s...:.r.•.w. sw •ma+F.wy+v rs.rr .c p THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH I t. .. No .............. . ... Fn........................ 19isposal Works Tunstrurtiutt Frrutit Permission is hereby granted........��..I__......._ri III................._ ` to Construct ( ) or Repair ( ) an Individual Sewage Disposal SSystem at No...... ....... .....1_nJ...................................................... � f ------••. ---------------------------------------- . 4 Street �_ � as shown on the application for Disposal Works Construction Permit No.............��� Dated........s..:........... ................ Cj O Board of Health DATE.............................................................................. A , -. SECTION :-SEWAGE",,- ,x b. DOXSEPTIC"TANK- -LEACH 2 , - . STONE : L V t d `N '"C PJ�i �W;t�,vAM tic:Yts k •WASFEO " v » s I i r�s C ) _ E w IN OUT. . _ IN- ,,,:, :, .•, _OUT i •r r , r.. r. SEPTIC < 5 TAN K Z 3 ELEV. ELEV'. ELEV. 1 , ELEV. 2 5,2 �, � nAt�lE - ELEV. ELEV. -' ,. -. D T E _.. _ ASHE 5 ON W i ' TEST HOLE LOG �T� aT of - 5 TEST BYOATrJ WITNESS - — - TEST DATE 7 DESIGN J B"EDROOM.HOUSE . / , i0 T.H. « 1 T.H. +� 2 I J - ELEV ELEV. NO L DISPOSER I PERC RATE MINAN. SPOSER ti (GA.✓DAY)FLOW RATE .110 I� A rQ9*,.A. SEPTIC TANK GFI'J51? �- REQ'D SEPTIC'TANK_SIZE �1V 1 ; ,t FA LEACH FACILITY , • . SIDE WAL {Z J) '''_.G/D. BOTTOM .�brL�z7'j= 7Q�, dJ { I G/D. TOTAL 21n7'0 rr Y USE: -LEACHING �r WATER ENCOUNTERED I ' A I < GI N IG' EN GINEER GIN' EER MUST SUPERVISE. y ' F r STALLS ION AND CERTIFY Its. WRITING NOTES ' (UNLESS h � � - �. { SS OTHERWISE H� - INSTALLED C SYSjrEM WAS INSTA D IN STRi -1 1.DATUM(MSU!.TAKEN FROM .-..QUADRANGLE MAP __ ')f`\IC= TO PL AN 2.MUNICIPAL WATER __".AVAILABLE t - 3.PIPE PITCH:W' PER FOOT . 4.DESIGN LOADING FOR ALL PRECAST UNITS:AASHO- •44 5.MIN.•GROUND COVER OVER.ALL SEWAGE FACILITIES:(1) FT. ro'.. �.i 6..PIPE JOINTS SHALL BE MADE WATER TIGHT � OU'AtA �, � u����G�V 7.CONSTRUCTION DETAILS TO BE ACCORDANCE WITH COMM.OF MASS. SITE STATE ENVIRONMENTAL CODE TITLE 5 N7�32 N ��pp � LOCUS N� � U�.D FOR .,PROPERI� U►.lE✓ �stD•KI cJC� � a F x -? ARNE r. o REG.'PROF O.AL`ENGINEER sT y L� H .'REF ALA . , :.; ... ,,. •.: . .. CQ e,-;:e� � �etl� - - 26 d8; PREPARED FOR: _ r.ClVll' ENGINEERS_ ...:_;,: E'� �< �• , ,... .. D . , ;...:_ `LAND LA O SURVEYORS - .. .. .... n$;>Y, ORaFHEEff ,Ihtlt .:SCALEi t . (E ISTl T . .r,. 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