HomeMy WebLinkAbout0134 OLD TOWN ROAD - Health 134 OLD TOWN RD., HYANNIS
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TOWN OF BARNSTABLE
LOCATION, `� owl SEWAGE# 6,4,' ��7
VILEAG) / oSESSOR'S'MAP&PARCEL«.,
INSTALLERS NAME&PHONE NO. (-)C- ►�+�►n
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type)2— SG® dE,c-Q L° (size) X 3- 1( f 2.S 7(Zs
NO.OF BEDROOMS Lf
OWNER fn r 'Ocwo
PERMIT DATE: 7—7— O(- COMPLIANCE DATE: d l0
Separation Distance Between the:
Maximum Adjusted Groundwater Table to'the Bottom of Leaching Facility Feet
Private Water Supply Welland 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
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No. 30-7 Ael 0 0.0 0
'THE.COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
21pplication for M.i5poal *p.5tem Cun5tructiutt permit
Application for a Permit to Construct( ) Repairs ) Upgrade( ) Abandon( ) ❑Complete System 91ndividual Components
Location Address or Lot No. Owner's Name,Address,and Tel.No. 7 7//5—3 5 5 3
134 Old Town Rd, W Hyannisport Ralph DeWolfe
Assessor's Map/parcel qj-9o&— 134 Old Town Rd, W Hyannisport
Installer's Name,Address,and Tel.No.7 7 5—8 7 7 6 Designer's Name,Address and Tel.No. 3 6 4—0.8 9 4
Wm E Robinson Sr Septic Eco-Tech
PO Box 1089 Centerville 143 Triangle Cir, Sandwich
Type of Building:
Dwelling No.of Bedrooms 4 Lot Size sq.ft. Garbage Grinder Oo)
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) /L1Cv - gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) Install a new Title 5 leach
syst-em to plans of Eco-Tech, #ETE-2356 (3)SRU 62i �s11
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 Certificate of
Compliance has been issued by this Board of lea th.
Signe Date 3 G'
Application Approved by Date 7''7--o _
Application Disapproved b J. Date
for the following reasons
Permit No. ��lv r ®� Date Issued 7 '-o( .
6
77"Y
No.. NO� ~ 30 7 Feel 00.00
— �,4'� + Entered in computer:
TI E4COMMONWEALTH�QF M-AS-SAC.HU:S_ETTS Yes
PUBLIC HEALTH DIVISION - TOWN OF BARI*S+TABL:E, MASSACHUSETTS
01ppY cation for Mg ogal *pftem tow5truction Permit
Application for a Permit to Construct( ) Repairg Upgrade( ) Abandon( ) ❑ Complete System IN Individual Components
Location Address or Lot No. Owner's Name,Address,and Tel.No. 7 7 5-3 5 5 3
134 Old Town Rd, W Hyannisport Ralph DeWolfe
Assessor'sMap/Parcel.�.�9.- :26 1; 134 Old Town Rd, W Hyannis port
b
Installer's Name,Address,and Tel.No.7 7 5—8 7 7 6 Designer's Name,Address and Tel.No. 3 6 4—0 8 9 4
Wm E Robinson ,Sr Septic Eco-Tech ,
PO Box 1089 Centerville 143 Triangle Cir, Sandwich
Type of Building:
Dwelling No.of Bedrooms 4 Lot Size sq. ft. Garbage Grinder :(10)
Other Type of Building No.of Persons Showers( ) Cafeteria
Other Fixtures
Design Flow(min.required) �+ L(y gpd Design flow provided '" gpd
Plan Date Number of sheets Revision Date
i
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) Install a new Title 5 leach
system to plans' of Eco-Tech, #ETE-2356 Ln SUU c � . x
-- be»�,
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 Certificate of
Compliance has been issued by this Board of Heath.
Signed" Date `s '3 G' G
Application Approved by y/ �{N Date —o h
t Application Disapproved by Date
' for the following reasons
' Permit No. 2 60 to 70-7 Date Issued ?----------------------------------------------
h {`
THE COMMONWEALTH OF MASSACHUSETTS
DeWolfe BARNSTABLE, MASSACHUSETTS
v
(Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( X) Upgraded ( )
abandoned( )by Wm E Robinson Sr Septic Service
at 134 Old Town Road, W Hyannisport has been constructed in accordance
with the provisions of Title 5 d the for Disposal System Construction Permit No. '�006—_ 3 0 7 dated -7—7—U4
Installer 1` b� r� Designer riz 14 J1O��
#, bedrooms 7 Approved design flow yV gpd
The issuance of this permit shall/ J
not be construed as a guarantee that the system will function as esi ne .
Date '7!/1 1 /� Inspector -
--.
No. 00G -3c)-7 goo.00
DeWolfe THE COMMONWEALTH OF MASSACHUSETTS 4
PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS
i ,
Bidw.,ogaY 6pgtent,60,n5truction 1�erMit
Permission is hereby granted to Construct ( ),--Rep ( X) Upgrade"(""'" ) Abandon
System located at 134 Old Town Road$ W Hvanni gnQr� t
a y
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: Constructidn must be completed within three years of the date of this ermit
Date 7I 0 Approved by
us., /r�I - 'N�(/rQ2W ��Owes rGn I "u er/�rr
Notice: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only
PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM
1, h y 1 t) D , COV6 HAS pw hereby certify that the engineered plan signed by me
dated Tutte V, ZDt concerning the property located at
G 4 ow Tow h Dad meets all of the
following criteria:
• Two soil evaluations excavated for detailed examination(no hand augering) and two
percolation tests shall be conducted.
• This failed system is connected to a residential dwelling only. There are no commercial or
business uses associated with the dwelling.
• The soil is classified as CLASS I and the percolation rate is less than or equal to S minutes
per inch.
There is no increase in flow and/or change in use.proposed
• There are no variances requested or needed.
• The bottom of the proposed leaching facility will-be located no less than five feet above the
maximum adjusted groundwater table elevation. [Adjust the groundwater table using the
Frimptor method when applicable]
I
Please complete the following:
A) Top of Ground Surface Elevation(using GIS information)
B) G.W. Elevation R'00 +adjustment for high G.W2-3
DIFFERENCE BETWEEN A and B 2-0 " 7 U
SIGNED ! S DATE: oT''�e ZI Za��
NOTICE
Based upon the above information,a repair permit will be issued for bedrooms
maximum. No additional bedrooms are authorized in the future without engineered septic system
plans.
I
gASeptic\percexcW.doc
,
Town of Barnstable
oF,K•� ,.
Regulatory Services
Thomas F. Geiler, Director
• BARNSTABM
'""'9•
t639
. Public Health Division
`08'
iArFO"A°�� -Thomas McKean, Director
200 Main Street, Hyannis, NIA 02601
Office: 508-8624644 Fax: 508-790-630 3
Installer& Desizuer Certification Form
Date: Sewage Permit# Assessor's 1IapWarcel 190
Designer: Eco-Tech Installer: Wm E Robinson Sr Septic
Address: 43 Triangle Circle Address: PO Box 1089
Sandwich Centerville r
On Wm E Robinson Sr Septietvas issued a permit to install a
(date) (installer)
septic Zsysteat 134 Old Town Rd, Hyannis based on a design drawn by
(address)
-Tech dated 06-21 -06
(designer)
I certify that the septic system referenced above was installed substantially according; to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State & Local Regulations. Plan revislOn or
certified as-built by designer to follow.
N OF MgSs cti
•4
DAVID GN
v COUGNANOWR N
( taller's Signature) No. 1093
S T'E��O
�gNITARtPN
000
(Designer's Sionature) (Affix Designer's Stamp Here)
PLEASE RETUILN TO B:11;LNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF
CONIPLIA-NCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM :u`D AS-BLt1LT CARD :\KE
RECEIN3=D BY THE BAR_NSTABLE PUBLIC HEALTH DIVISION. THANK YOU.
Q: Healta-:SepticiDesigner Cenificauon Four
Notice: This Form Is To Be Used For th:e.Repair Of Failed
Septic Systems Only
PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM
I, )h v 1%) D . COUG HN c 1 hereby certify that the engineered plan signed by me
dated lung 7-11 2,0 concerning the property located at
meets all ofthe
following criteria:
• Two soil evaluations excavated for detailed examination (no hand augering) and two
percolation tests shall be conducted.
• This failed system is connected to a residential dwelling only. There are no commercial or
business uses associated with the dwelling.
• The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes
per inch.
There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
• The bottom of the proposed leaching facility will-be located no less than five feet above the
maximum adjusted groundwater table elevation. [Adjust the groundwater table using the
Frimptor method when applicable]
Please complete the following:
A) Top of Ground Surface Elevation (using GIS information) �7 00
B) G.W. Elevation R'e0 + adjustment for high G.W?,3 = 10 6
DIFFERENCE BETWEEN A and B 2-0 " 7 U
SIGNEDC DATE: OTC h e 21, ZOU�
NOTICE
Based upon the above information, a repair permit will be issued for bedrooms
maximum. No additional bedrooms are authorized in the future without engineered septic system
plans.
gASeptic\percexemp.do c
TOWN,OF BAMSTABLE �
' LO A'11110N h � SEWAGE #
V tLAGE .f�.�t/1'_C ASSESSOR'S MAP & LOT r
INSTALLER'S NAME&PHONE NO.I1 Ib GZ/0&-- &'E'410
—V
r "SEPTIC TANK_ CAPACITY d O
i
LEACHING FACILITY: (ty ) _ 7` f�/� �3 (size)
NO.OF-BEDROOMS
BUILDER OR OWNER.
PERMITDt;TE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottorgof leaching Facility
Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site i 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
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'V L=.LAGE ► �v aS -- AaScS`i0E?'S trLo & LOT a�� ® .
INST;L LER'S NANLE& PHONE NO.
SEMIC TAM{ CAPACITY' —UF],-x4J
LF ACFiG FACE TTY: (tyre) ® CESS. M (size)
NO. OF BEDROOMS
BLUDER OR OWNFR
SPATE:_ I OkAZA CIS COMPLIANCE DAir-:-- --
Separation Distance Between the:
hlaximttm Adjusted Grot ndwater T!hie.' ` _, I ----
Private Water Supply Well and Leaching Facility (Lf any wells exist
or.site or within 200 feet of lcac�:ing facility)
Edge of NVedxid and Leaching Faci!iry (If any wetlands ems:
withi, 300,fcet of leaching taciii^y,!
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cd
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No.
ay �✓_ J Fee S
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
01ppfication for Mf5paar *pgtem Construction Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) 'Complete System ❑Individual Components
Location Address or Lot No. 1 L` 0 1 \ t O Owner's Name,Address and Tel.No.
Assessor's Map/Parcel 7 �_ DO f �'' G
Installer's Name,Address,and Tel.No. L / Designer's Name,Address and Tel.No.
v> S, _C,1
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow "A%A 0 gallons per day. Calculated daily flow (2,7 gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank 1 0_V +A G' Type of S.A.S. C G t
Description of Soil 0 It%
Nature of Repairs or Alterations(Answer when applicable)
-T:7iV-e 0 Cr,Dc.G:-T� - ��.`l-o-��o 'So Pl
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 bee '
Signed -t. Date '� FJd
Application Approved by Date J- 2;r-
Application Disapproved for the following reason
Permit No. `7,r" -U q.7 Date Issued
No. � _ .�• Fee
V THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
Application for Migpogar *p! tem Congtruction Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) '+Complete System ❑Individual Components
Location Address or Lot No. 13`, U T— Owner's Name,Address and Tel.No.
Assessor's Map/Parcel O
Installer's Name,Address,and TeTel.'No. Designer's Name, (Address and Tel.No.
t 0--G.vc� r l
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
rt fir, Other Fixtures r
Design Flow V-A%J�0 gallons per;day. Cale ulated daily flow 6 / gallons.
Plan Date Number of sheets' Revision Date )
.,_.
Title
Size of Septic Tank 1 � O-D �)O Lk, / Type of S.A.S. 1 ti c �`
Description,of Soil: ►/ 6=0- C.a
t
Nature of Repairs o Alterations(Answer when applicable) 1'4�- ��'�`t v G KI•� t2- 1�- G
=r V cd. r C, G -C.T� oVZ S C.c. t.�t _S C tti..e_.
Date last inspected:
i
Agreement: ,r
The undersigned agrees to ensure-the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the"._provisions`of4Titld'5-'df the Environmental Code and not to place,:the sy,stem,in,operation until a Certifi-
cate of Compliance has beef issu ""
Signed 'Date
Application Approved by 00CDate
Application Disapproved for the following reason
Permit No. `Z -" -0 y J Date Issued //z J">/?,ea'.2
-------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of (Compliance
THIS IS TO CERTIFY,that the On-site Sewage Dis osal System Constructed( )Repaired( )Upgraded(
Abandoned( )by trn i 'D--c-A - �C_
at S-I'A O W-1CV41 6 Ltl kv-14 S IPc it I has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No.Ze- '%1 dated
Installer Designer A /
The issuance of/ s permit/shall not be construed as a guarantee that the system,V.will function as designedf
Date 6),r Inspector
---l✓7 v—,-----------------------------------
No. y v ''`}(/3 Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
wigpogaf *pgtem Construction Permit
"Permission is hereby granted to Construct( )Repair( )Upgrade( )Abandon( )
System located at 1 ®l 0-1(—�- -- y(�
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 nermit.
Date: ��� S�� Approved by211e_�I:Z 6�
1/6i99
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only. -
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERtiITI' (WITHOUT DESIGNED PLAYS)
I, J ,C•` hereby certify that the application for disposal works
construction permit signed by me dated UCH concerning the
property located at meets all of the
following criteria:
LThe failed stem i c nner ed 'system s a to a residential dwelling only. Tne.e are no commercial or business
/uses associated with the dwelling.
• The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch.
C/ There are no wetlands within 100 feet of the proposed septic system
V-7nere are no private wets within 150 feet of the proposed septic system
A- ere is no increase in Clow and/or change in use proposed
6/There are no variances requested or needed.
�ine bottom of the proposed leaching fa
will not be located less than five feet above the
maximum adjusted groundwater table elevation. (Adjust the groundwater table using the Frimptor
method when applicable]
�-�` If the S.A.S. will be located with 2f0 feet of any vegetated wetlands, the bottom of the proposed
leaching facility will not be located less than`ouncen(14) Feet above the maximum adjusted
groundwater table elevation,
Please complete the following: /
A) Too of Ground Sur�fa/ce Eicvation(using GIS ini6rmation) I ,
B) G.W. Elevation the NLk.X. High G.W. Adjustment . r c
D 1F cREN CE BETWEEN a.and B
SIGNED : DATE:
[Sketch proposed plan of systern on back].
q:ic:L!h folder.c-t
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TOWN OF BARNSTABLE
LOCATION L24 6 L h zr a h/ //Z C� - SEWAGE # U 3
i VILLAGE .furl -C ASSESSOR'S MAP &LOT
INSTALLERS NAME&PHONE N0.
{
SEPTIC TANK CAPACITY /` �d,0
LEACHING FACII:TTY: (ty rA/� (size)
NO. OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: - COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottorq of Uaching 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
VA
oMa V•
t�e+ - :J. ,y •:e �sew�u`�t��. �"�.\.arp.��,. d i i 'r v�Jw P'.�'`�4`. �k"'`. T `}��;'y"�,�d.'
• M i i tia + a wr ,�}< 'e
1: 17
M� $ .+i"�:,;t a /.•dR `�� 'fie'- aic.,�•1^
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y
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�}ry�g:� ys;♦..'�.�* .�; 4e� ,'. ' ��4.� Nay.
a
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�tud#w�•e q'
Joseoh NI
I Bettencourt X
verify location I General Notes:
knee
• f o fed wall I — Contractor shall install clips,blocking and
BED ROOM-1 o straps as required by building code. !
i O — Contractor shall confirm all dimensions in
l field prior to beginning construction �... v
Contractor and owner shall select all
/ I — finishes, windows, doors and roofing Ii
11 existing-/ Home owner and contractor to set -
!) roof final location for windows
framing
q
a to remain
this side of
ridge N.aentrel Street
xi t n O aeaeoay.Ma
s air BATHROOM I 508-527-4107
t r a n
i --_ El I
verify location I BED ROOM-2
of knee wall
in field I - Z'•` o
I 0
O
existing existing
roof roof
below below
Y
Proposed Second Floor Plan r, Proposed Roof Framing Plan N
v r
Roof Construction: �
— 2••x10•• rafters 16'•o.c. �^
— r-38 batt insulation 0
— 5/8" plywood sheathing []
— building paper
new ridge — roofing to be selected
by owner and contractor (y
— install J'• strapping
new drywall ceiling and point
finish
Exterior Walls:
— 2••x6" walls studs
— r-19 butt insulation 7-5-2017
— vapor barrier
71 — drywall with paint finish
— exterior shingles and
/ / trim to match existing
Existing First Floor to Remain J Existing First Floor to Remain-
COMMONWEALTH OF kSSACHUSETTS
EXECUTIVE OFFICE OF E1'VIROhA4ENTAL FAIRS,
�`•
�� 4
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET. BOSTO\ MA 02108 16171 292.550� .
TR,U ,Y_Q0x_
OCT 2 8 1999 �-.E•��
E t. t0"0FBggfy 'ID B S hp
ARGEO PALL CELLUCCI W{�A�L�T�H� "•'r+iLtrl� CO�ITl355:_-,E'
Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A Ilb
CERTIFICATION `- 8
V{ b `�9-�,�J� Name of Owner .�-e, `r 1 -C \otic
,3�`
Property Address: ``
` tr%clress
of Owner:
Date of Inspection:. l
Name of Inspector:(Please Print) .G�+ `r ELK U
I am a DEP approved system inspector pursuant to Section 15.[[340 of Trde 5/(311y0 CMR 15.000)
Company Name: Fk N *y.t.-.,_ r L.Tu
MaiLng Address:-7,.'j /L., r
Telephone Nu-mn 2Z /4 Z-G
CERTIFICATION STATEMENT
1 certify that 1 have personally inspected the sewage disposal system at this address and that the information reported below is true. accurate
ection was performed based on my training and experience in the proper function and
and complete as of the time of inspection. The insp
maintenance of on-site sewage disposal systems. The system.
Passes
_ Conditionally Passes
_ Needs Further Evalu tion By the Local Approving Authority
_ Fails
Inspector's Signanrre:
Date:
The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or OEP)within thirty (30) days of
completing this inspection. It 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 Department of Environmental Protection. The original should be sent to ttre
system owner and copies sent to the buyer, if applicable. and the approving authority.
NOTES AND COMMENTS 1
S�� ��—�Gb\ � vv•C.�(.���O w ��Q.A�-�CX'>\ l �yS�r��
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. N rLow � 6U�-�(. �lUvv �-�--�Poc� S
revised 9/2/98 . Page Ior11
`� Prmud on Recycled Piper
t
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (corrtinuedl
+ropeM Address: �J l
})wner:
� Date of Inspection:
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
I onditions described in 310 CMR 15.30 exist. Any failure
have not found any information which indicates that any of the failure c
—T� criteria not evaluated ere�indficated below
COMMENTS:
B. SYSTEM CONDITIONALLY PASSES:
m
One or ore system components as described in the "Conditional Pass' section need to be replaced or repaired. The system, upon
P-6
completion of the replacement or repair, as approved by the Board of Health, will pass.
ribe
of
etermination in
instances. If "not
n why not.
Indicate yes, no. or The septic trank isY metal, unless Dthe cowner aorsoped l
not operator has provided system inspector ewith ra copy of al
tCertificate of
Compliance(attached) 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 infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
_ ter level observed in the distribution box is due to broken or obstructed pipe(s)
Sewage backup or breakout or high static wa
or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health).
broken 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 pipe(s). The system will pass
Inspection if (with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
revised 9/2/98 Page?ofu
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: '
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303 (1)(bl THAT.THE SYSTEM
IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
_ Cesspool or privy is within 50 feet of surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
i
j,
21 SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTW(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
_ The system has a septic tank and soil bsorption 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�oil absorption system and the SAS is within a Zone I of a public water supply well.
_ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for eoliform bacteria and volatile organic compounds indicates that the
well is free from pollution frgm 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 9/2'/98 Page 3of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM • ,
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
D. SYSTEM FAILS:
You must,indicate either "Yes" or "No" to each of the following:
I have determined that one or more of the following failure conditions exist as describgd in 310 CMR 15.303. The basis for this
determination is identified below. The Board of Health should be contacted to deter ine what will be necessary to correct the failure.
Yes No /�
Backup of sewage into facility or system component due to an overlos ed or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
_ Static liquid level in the distribution box above outlet invert due?to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
Any portion of the Soil Absorption System, cesspoo Zorprivy is below the high groundwater elevation.
— — Any portion of a cesspool or privy is within 10t�,eet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Done I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If thS/well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic cornpounds, ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No" to each of the following:
The following criteria apply to large systerrl's in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public
health and safety and the environment 'ecause one or more of the following conditions exist:
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 locatediin 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 system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further information.
_ t
revised 9/2/98 PaRe4eftl
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
property Address:
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 Np
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 part of this
inspection.
As built plans have been obtained and examined. Note if they are not available with N.'A.
The facility or dwelling was inspected for signs of sewage back-up.
J\ _ The system does not receive non-sanitary or industrial waste flow.
The site was inspected for signs of breakout.
_ All system components. excluding the Soil Absorption System, have been located on the site.
The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles
or tees, material of construction, dimensions. depth of liquid, depth of sludge. depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
Existing information. For example. Plan at B.O.H.
Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable)
115.302(3)(b)) -
The facility owner (and occupants, if different from owner) were provided with information on the propermaintenaaca-0f
SubSurface Disposal Systems.
revised 9/2/98 eagescril
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM.
PART C
/�(� > SYSTEM INFORMATION
'roperty Address: � 6a
Owner:
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow:]gg•p•d./bedroom. j
Number of bedrooms (des' n):� Number of bedrooms (actual):(SL
Total DESIGN flow_
Number of current residents:
Garbage grinder(yes or no):
Laundry (separate system) (yes or no):-L",: If yes, separate inspection required
Laundry system inspected (yes or no)
Seasonal use (yes or no): Iv
Water meter readings, if available (last two year's usage (gpd): (ti
Sump Pump(yes or no):_�
Lest date of occupancy:2GytT1n5 elR ld J�
COMM ERCIALANDUSTRIAL:
Type of establishment:
Design flow: qpd 1 Based on 15.203)
Basis of design flow
Grease trap present: (yes or no)_
Industrial Waste Holding 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:
OTHER:(Describe) _
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of informal n:
System pumped as part of inspect on: (yes or no)_
If yes. volume pumped: gallons
Reason for pumping:
TYPE OF SYSTEM
Septic tank/distribution box/soil absorption system
Single cesspool
i
Overflow cesspool
C— Privy
Shared system(yes or no) (if yes, attach previous inspection records,if any)
I/A Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components, date Installed lif known) and source of information:
Sewage odors detected when arriving at the site: (yes or no)1 j"1
revised 9/2/98 Pece6aII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (corrtinued)
'roperty Address:
Owner:
Date of Inspection:
BUILDING SEWER:
(Locate on site plan)
i
Depth below grade:_
Material of construction:_cast iron_40 PVC_ other (explain) /
Distance from private water supply well or suction line
Diameter
Comments: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK:_
(locate on site plan)
Depth below grade:_
Material of construction: _concrete_metal_Fiberglass _Polyethylene other(explain)
If tank Is metal,list age_ Is age confirmed by Certificate of Complian e _(Yes/No)
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:
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:
How dimensions were determined:
'omments:
(recommendation for pumping, condition of inlet and outle/ees or baffles, depth of liquid level in relation to outlet invert. structural integrity,
evidence of leakage, etc.)
i
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 outlete or baffle:
Distance from bottom of scum to bottom f outlet tee or baffle:
Date of last pumping:
Comments:
(recommendation for pumping. condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage,etc.)
x
revised 9/2/98 page 7of11
)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION Icontirwed) /
i
'roperty Address:
Owner: %
Date of Inspection: /
I
TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) %'
(locate on site plan)
Depth below grade:_ other(ex lain)
Material of construction: _concrete _metal _Fiberglass_Polyethylene_ P /
Dimensions:
Capacity: gallons Design flow: gallons/day
Alarm present
Alarm level: Alarm in working order: Yes _ No_ �-
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:_
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal, evidence of solids carryover, vidence of leakage into or out of box, 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 pum s and appurtenances,etc.)
i
revised 9/2/98 Pagc8ofII
a
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
�( SYSTEM INFORMATION (continued)
`roperty Address: -\C)k .{��"'L&-�V-j
Owner:
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS):
(locate on site plan, if possible: excavation not required, location may be approximated by non-intrusive methods)
If not located, explain:
Type:
leaching pits, number:_
leaching chambers, number:_
leaching galleries, number:_
leaching trenches, number, length:
leaching fields, number, dimensions:
overflow cesspool, number:—L�5x�
Alternative system:
Name of Technology:
Comments:
W(notendit'on of s il, igns of hydra lic failure, level of ponding, damp soil conditio o(vege io tc.) l
v Mlni
CESSPOOLS:
(locate on site p an)
Number and configuration: v
Depth-top of liquid to inlet invert: l
,r
Depth of solids layer: "}61_
)epth of scum layer: rD`t
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow (cesspool must be pumped as part of inspection) 1
Comments:
in to condition of soil„si ns of hydraulic failure, level o onding, condition of veg tation, e .1_
C
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.)
Pa�c9eru
revised 9/2/98.
L
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
'roperty Address:
Lt Gl��w vJ
)wner:
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
g
�z
y7
revised 9/2/98 Page 10ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
ropetty Address: �✓ v\� t/`'
Owner:
Date of Inspection:
NRCS Report name f �
Soil Type_ ---
Typical depth to groundwater_ _. _
USGS Date website visited w
Observation Wells checked
Groundwater depth: Shallow Moderate Deep
SITE EXAM Slope "
Surface water
Check Cellar N(f4
Shallow wells V'O
Estimated Depth to Groundwater �61`eet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observed Site (Abutting property. observation hole, basement sump etc.)
Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
Checked pumping records
Checked local excavators. installers
Used USGS Data
Describe how `you established the High Groundwater Elevation. (Must be completed)
cS c IOC
revised 9/2/98 Page 11of11
_ : = COMMONWEALTH OF NL%SS'+CH17SETTS
_= r, EXECUTIVE OFFICE OF E�-vIROI�D4ENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE nTNTER STREET. BOSTON Ni.
021(J6 (617J 292-�:i(fu
TRUDY COS:-
Secre:ar-
DAVID B. STP. •r.�
ARGEO PAIL CELLUCCI Commiss'_-.r
Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
if CERTIFICATION
1SLk b� L�JJ-W Name of Owner a�RSt(�`rl �'t+``�N�
Property Address:
1 Address of Owner:
Date of Inspection:. `
Name of inspector:(Please Print) �C f+ � EL U
1 am a DEP approved system inspector pursuant to Section 15.(340 of True 5(3e1,0 CMR 15.0001
Cornpany Name:
Mang Address:Ffen A^ 4 7 :3 yC._Le
Telephorm Number:
CERTIFICATION STATEMENT
age disposal system et this address end that the information reported below is true. accurate
1 certify that I have personally inspected the sew
ection was performed based on my training and experience in the proper function and
and complete as of the time of inspection. The insp
maintenance of on-site sewage disposal systems. The system:
Passes
_ Conditionally Passes
_ Needs Further Evalu tion By the Local Approving Authority
_ Fails
Inspector's Signature:
Date:
The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEPlwithin thirty (30) days of
completing this inspection. It 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 Department of Environmental Protection. The original should be sent to the
system owner and copies sent to the buyer,if applicable, and the approving authority.
NOTES AND COMMENTS
s_RVV^ w<< < � u���zc, �I�S � � r�tiV4—v�
6Ut�'c F(ct/,j Poci s
N
revised 9/2/98 Page Iof11
h Printed on R"Ied Paper
a �W
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
« per CERTIFICATION (corrb—ed)
►roperty.Address: LSq o l 1
Jwner:
Date of Inspection:
INSPECTION SUMMARY: Check A, B, C, o/ D:
A. / SYSTEM PASSES:
I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure
criteria not evaluated are indicated beloOA
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.
Indicate yes, no, or not determined(Y, N. or ND). Describe basis of determination in all instances. If 'not determined explain why not.
_ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
(attached) indicating that the tank was installed within twenty (20) years prior
rito the dotion or of the inspection;
tank
Compliance turall unsound, shows substantial
' crocked. structurally the septic tank, whether or not metal, is
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
_ ter level observed in the distribution box is due to broken or obstructed pipelsi
Sewage backup or breakout or high static wa
or due to a broken, settled or uneven distribution box. The system will pass inspection it (with approval of the Board of
Health).
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced "
_ more than four times a year due to broken or obstructed pipe(s). The system will pass
The system required pumping
Inspection if (with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
revised 9/2/98 t.4311G Page 2oru
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and 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 THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
_ Cesspool or privy is within 50 feet of surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
i
2) SYSTEM WALL FAIL UNLESS THE BOARD OF HEALTW(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS
FUNCTIONING IN A MANNER THAT PROTECTS THE'PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
_ The system has a septic tank and so71bsorption 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 andril absorption system and the SAS is within a Zone I of a public water supply well.
_ The system has a septic tank and'soil absorption system and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank apt soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well,unless a well water analysis for eoliform bacteria and volatile organic compounds indicates that the
well is free from pollution fr9m that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm. Method usedAo determine distance (approximation not valid).
3) OTHER
J'
�I
t
revised 9/2/98 Page 3 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM /
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
D. SYSTEM FAILS:
You must indicate either "Yes" or "No" to each of the following:
1 have determined that one or more of the following failure conditions exist as describgd in 310 CMR 15.303. The basis for this
determination is identified below. The Board of Health should be contacted to dete7ine what will be necessary to correct the failure.
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 to an overloaded or clogged SAS or
cesspool.
_ Static liquid level in the distribution box above outlet invert dueIto an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or avaiila le volume is less than 1/2 day flow.
_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipelsl.
Number of times pumped_
System, cesspoo/or privy is below the high groundwater elevation.
_ Any portion of the Soil Absorptiony ,
Any portion.of a 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 I of a public well.
— — J
i
_ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the rwell has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS: /
You must indicate either "Yes" or "No" to each of th�following:
The following criteria apply to large systerrls in addition to the criteria above:
The system serves a facility with a desrqn/flaw of 10.000 gpd or greater(Large System) and the system is a significant threat to public
health and safety and the environmentpecause one or more of the following conditions exist:
r
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 we11)
The owner or operator of any such sy/em shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further i/formation.
/
revised 9/2/98 page 4ertl
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 3� '5 jj TOvJV3
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 NO
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 part of this
inspection.
As built plans have been obtained and examined. Note if they are not available with N.A.
The facility or dwelling was inspected for signs of sewage back-up.
Jl _ The system does not receive non-sanitary or industrial waste flow.
The site was inspected for signs of breakout.
_ All system components, excluding the Soil Absorption System, have been located on the site.
The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles
or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
Existing information. For example, Plan at B.O.H.
Determined in the field(if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable)
(15.302(3)(b))
The facility owner land occupants.if different from owner) were provided with information on the propermaint,enanr�-0f
Subsurface Disposal Systems.
Y
r vise d 9/ /
2 9
8 Page of 11
e
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
//��((�� SYSTEM INFORMATION
v
'roperty Address: ��kk `J•-'a
Owner:
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow:g•p•d•/bedroom.
Number of bedrooms (desi n):b-91 Number of bedrooms (actual):aL
Total DESIGN flow
Number of current residents:
Garbage grinder(yes or no):
Laundry(separate system) (yes or no):-L'�: It yes, separate inspection required
Laundry system inspected (yes or no)
Seasonal use (yes or no): I3
Water meter readings, if available (last two year's usage(gpd):
013
Sump Pump(yes or no):
Lest date of occupancy:
XIAS
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow: qpd ( Based on 15.203)
Basis of design flow
Grease trap present: (yes or no)_
Industrial Waste Holding 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:
OTHER:'(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of informat' n:
Ma
System pumped as part of inspect on: (yes or no)_,
If yes, volume pumped: gallons
Reason for pumping:
TYPE OF SYSTEM
Septic tank/distribution box/soil absorption system
Single cesspool
�t Overflow cesspool
—�'c— Privy
Shared system (yes or no) (if yes, attach previous Inspection records,if any)
I/A Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components, date Installed lif known) and source of information:
Sewage odors detected when arriving at the site: (yes or no)
revised 9/2/98 page 6orII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
'toperty Address:
Owner:
Date of Inspection:
BUILDING SEWER:
(Locate on site plan)
Depth below grade:_ %
Material of construction: _cast.iron_40 PVC_ other (explain) /
Distance from private water supply well or suction line
Diameter
Comments: (condition of joints, venting, evidence of leakage, etc.) f
SEPTIC TANK:_
(locate on site plan)
Depth below grade:_
Material of construction:_concrete_metal _Fiberglass _Polyethylene other(explain)
If tank is metal, list age_ Is age confirmed by Certificate of Complian e_(Yes/No)
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:
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
How dimensions were determined:
'omments:
(recommendation for pumping, condition of inlet and outlet ees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage,etc.)
1 .
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 ee or baffle:
Distance from bottom of scum to bottom f outlet tee or baffle:
Date of last pumping:
Comments:
(recommendation for pumping, eondit5 n of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage,etc.) /
r,.���onl
revised 9/,2/98
R
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued) /
'roperty Address:
i
Owner: /
Date of Inspection:
i
i
TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) /
(locate on site plan) %
Depth below grade:_
Material of construction: _concrete _metal _Fiberglass_Polyethylene_other(explain) %
i
Dimensions: /
Capacity: gallons %
Design flow: gallons/day i
i
Alarm present
Alarm level: Alarm in working order: Yes _ No_ `
Date of previous pumping:
Comments: /
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:_
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal, evidence of solids carryover, vidence of leakage into or out of box, 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 pum s and appurtenances, etc.)
--------------
i
revised 9/2/98 Page 8ofII
a
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (contirwed)
,roperty Address:
Owner:
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS):
(locate on site plan, if possible; excavation not required, location may be approximated by non-intrusive methods)
If not located, explain:
Type:
leaching pits, number:_
leaching chambers, number:_
leaching galleries, number:_
leaching trenches, number, length:
leaching fields, number, dime ions:
overflow cesspool, number: j��
Alternative system:
Name of Technology:
Comments:
(note condition of s il, igns of hydra lic failure, level of ponding, damp soil conditic o vege io tc.l l
v
CESSPOOLS:
(locate on site p an)
Number and configuration:
Depth-top of liquid to inlet nlvert: I
Depth of solids layer:
)epth of scum layer: 'I
Dimensions of cesspool: I CCU
Materials of construction:
Indication of groundwater:�0
inflow(cesspool must be pumped as part of inspection) r"�
Comments:
(n to condition of soil, ns of hydraulic failure. level o onding, condition of veg tation, e
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 9/2/98 Page 9ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
'roperty Address: 1 vKJ t6v"
)wner:
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
6
�z
revised 9/2/98 Page looriI
1
e
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
ropetty Address:
Owner:
Date of Inspection:
NRCS Report name --
Soil Type_ ---
Typical depth to groundwater_ _-
USGS Date website visited V
Observation Wells checked
Groundwater depth: Shallow Moderate Deep
SITE EXAM Slope
Surface water
Check Cellar 1-4►4
Shallow wells V-O
Estimated Depth to Groundwater �OFeet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observed Site (Abutting property. observation hole. basement sump etc.)
Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
Checked pumping records
Checked local excavators. installers
Used USGS Data
Describe how you established U &Cvc
the High Groundwater Elevation. (Must be completed)
00
revised 9/2/98 Page 11 of 11
FEs_.._�
TH MONWEALTH OF MASSACHUSETTS
'f ARD OF HEALTH
1 ........!W.... ......................OF.....lr//O/��J/.® C..........-.....-.............._._.... — G�— ��
Appl ration for Disposal Works Tonstrnr#ion Frrmi# -
Application is hereby made for a Permit to Construct Ik) or Repair ( ) an Individual Sewage Disposal
System at:
/17.?r/ /,/ /?J.
eddres -�•-
s a: a xo_..__-.�.._.._.__.... ....
..... �:�. ..�, . � . b.._._....-..-- .. i�...... �..�1 --•---._...__._...
Address
G• �j�jPA/i'L
Installer Address
Type of Building Size Lot-.A..A -`_.-..Sq. feet
., Dwelling—No. of Bedrooms............................................Expansion Attic (Lf Garbage Grinder ( )
Other—Type T e of Building No. of persons............................ Showers
W YP g ----••---------------------- P ( ) — Cafeteria ( )
a' Other fixtures ......................•------_.... . ..
WW Design Flow............................................gallons per person per day. Total daily flow...__-324?7.......................gallons.
Ix Septic Tank—Liquid'capacity/AP. .gallons Length................ Width................ Diameter................ Depth.................
Disposal Trench—No. ..................:. Width.................... Total Length.................... Total leaching area........ ----...sq. ft. 1
Seepage Pit No.........Z........ Diameter./ ............ Depth below inlet.. �......... Total leaching area-.. ! .....sq. ft.
z Other Distribution box ( ) Dosing tank )
1.4 Percolation Test Results Performed by..____, `l /l _-._--- Date-----5/ .........
1.4 1.4 Test Pit No. 1................minutes per inch Depth of Test Pit............ epth to ground water....! ...........
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water,f. .�..._..._...
a .............•--- --- ................................... -----------------------•------ ---
O Description of oil----n �.. ....._..�A ... ._... ii/8 sT..a t._._ /�..-=-l..f?..'... Q•Oil E'.................d`'
W ----•...---•--------•---•-•-•--------................................................................................... •-•-•--------•---•------•---------••-------•-••--•••-•----•..._......-•-•.....
U 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 TIT1Z 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the Vard of health.
v`
Sign --••-•----•----•-•.......... ... ..--.-........_.. � �7.
_ Date
Application Approved By--------- f .• .... :...... .. •-• . - �."..._.... _ ....................
Date
i
Application Disapproved for the following reasons:..........................................................................................................___
---•----------•--.--••--••-•-----...----•-••-----------------------------•••••--•••-•-----.._.._.._..••-----....•--•----------•-------•-••--•--•-••-------•---------••-•--•--•---....----...----••----
Date
PermitNo.................................-------------_..._..... Issued.....•.0:. - . .......-------
Date
No............... ..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.../�.. , .......................OF.. J=�.
..................................................
Appliration for Disposal Works Tomitrn.rtion rumit
Application is hereby made for.a Permit to Construct ,(�') or Repair ( ) an Individual Sewage Disposal
System at
....... .....�� ............................................................ ------.. .. ...........
Locat Address or Lot No
(�.i ------------- ., CC r'!�! le Lot
Owner Address
...
-•--•............... �-......--•-----••--------•--......--•----- ........--------•------ -••---•--•--------•----- •--------•--...------...........�-----
Installer Address
Type of BuildingSize ............Sq. feet
Dwelling—No. of Bedrooms-----...�:............................Expansion Attic (Z'') Garbage Grinder ( )
PL4Other—T e of BuildingNo. of persons............................ Showers — Cafeteria
P4 Other fixtures --------------- ----•----•-•... . _
W
Design 'Flow............................................gallons per person per day. Total daily flow......� 0.........................gallons.
WSeptic Tank—Liquid capacity/rM'zs?.gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No---------/..--------- Diameter./4:........... Depth below inlet._6-__.......... Total leaching area..:` �-----sq. ft.
Z Other Distribution box ( ) Dosing tank
'-' Percolation Test Results Performed by......� rl " r'�...�✓l �� eol"': ?_..._.... Date.....s/.../�.
Test Pit No. 1................minutes per inch • Depth ofy Test Pit.................... Depth to ground water..A -----
Test Pit No. 2....... _a....minutes per inch Depthy of Test Pit.................... Depth to ground water�A ,...............
a
--------•-------�---u---�--J--r----l--------- --••-••---_-•.•-�•---...y.....-----S......f...a-•-r•••......- ..•-•----'•'••-•--•---•--------•-----�••-•1--.."....••fi--e-.;.;..-
O Description of Soil - - .. .. ........... --.--- -----•- _ 7---------
._.___•__•U ..--................................................--.__.............................._............_...._.____....
W
UNature of Repairs or Alterations—,A�wer when applicable...............................................................................................
....................................................�._._«k._............._......_..............................-----------•----................_._.....................................................
Agreement: r
The undersl ed agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions 7.LTILL 5 of the State Sanitary',Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the h board of health.
Sign ,+ N7�:: �1 Z'��'/�...... ..........................f •--
Date
Application Approved B ..
c _ -------------------Date I
:,.
Application Disapproved for the following reasons---------------------------------------------•-...............................
.......................................••-----•----------------------------...-----------............-------••---------------•--••------------.._...-•--•-•------•---------•---•----•--•-•-------------
Date
PermitNo......................................................... Issued.........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
(In ifiratr of TonipliFanrr
THIS IS TO CE)2TIFY, That the Individual Sewage Disposal System constructed O or Repaired ( )
by----. ,rr '.4dVf r ...................... -- -----------....---......----•-••---•-••--•-----•.
/ Installer
`� (j/fir 1�t I;�." ✓,✓lip`% ,di ! �a i r ;
at ------------ - x---------------- ... .. . �' '
has been installed in accordance with the,* ovisions of F 5 The State Sanitary Code as described in the
application for Disposal Works Construction Permit N .. .._"".. 1_T_?.2. ._....... dated_---- `.��_°^':_..��.__.....
THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONST ED AS A GUARANTEE THAT THE
SYSTEM W L
. FUG FACTORY.
pDATE..... --------------------------- s. ector....._.. _
...
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
7 J 7. ..........` Z`� .i1..................0F... '. s
No................... ... FEE........................
M.5posal Worko Tonu#r inn rrmit
Permission is hereby granted.....6�-`x.-�f-:_. '14�r
-----------------------------------••---------------------------•--..........---...........-•-.-----
to Construct44-") or Repair ( ) an/Individual Sewage Disposal Systems , y
at No.....ie�.... 1r. .. c `= 1 fir:z i ,.f.+-,f .ri ::.............
� d......
Street ' •''
as shown on the application for Disposal Works Construction P No. .._..._.. .. /at�e'd.�...//-_. .. ....:
DATE-...... " / ------•------••------•---•---•----• Board of Health
r.
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS '•b., .
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' EXISTING '.`SPOT ELEVATION 0x0 , ' CERTIFIED PL"'OT , «'PL�jANir-e1
`EXISTING : CONTOUR = _ — p '_ "-
_F_INiSHED.. SPOT E•LFVATION (0
FIN�SHEO CONT_OS1R -- 0 — } ��f Y� 'j=S `' � e� -; a
_�
tt/ ,
1 N ,. �Via,
APPROVED . BOARD ` ' ' _ '`,i , ' ' �' =''t OF HEALTH r� W„ ': I
F `-
DA-T`E AGENT SCALE �:;; �'Sq �.. nt
f{ %. 3d dATE t.,. 79 �
`' [_4DREDGE ENGINEERING CO ING�.
;l—... a . ,..�' -; c� pk} t you
C L I E N t 1M���►YE
i, CE,RtTIFY THAT 'THE ROtQSE r�`,r�t.`
a� EGISTERE REGISTERED J08,:RNd 7,� d2,b BUILDING .SHOWN ON THIS ( PLANSr �`
CIVIL ! LAND CONfORMS ' TO 7HE: .ZONLNG '. '`A r'�jiL.
C. ' ,ENGINEER SURVEYOR Al
DR BY .4t,'A OF BARNSTA®LE MA S. Lw WS
I 3� NG. MAIN ST : 712' _MAIN\ ST.` .. CH. B. _._: _— &,r� • �;l
SO YARMOUTH, .MASS. HYANNIS, MASS. Z, / - , 'S'-'%
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No.- --- Fps.......... ............
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
TOWN OF BARNSTABLE
, ppfirFa#ion for Uiipn,o al Works Tan rnrtiun Frrutit
Application is hereby made for a Permit to Construct ( ) or Repair 0<") an Individual Sewage Disposal
System at:
... ---�c�.... ---•.. ......... ........ s......_._ ..._...__.._........_..._........ -
Location-Address / or Lot No.
......gam..........r. G O f 'J Lt/!4!! --- = T Dom...�...
7/ C_L^, ' Addres /�`r
.....................................nst --•...1.....-------------t---•-•----------- ..... T- - �"
Installer Address mac.,
dType of Building Size Lot s. ....d- __.Sq. feet
V Dwelling—No. of Bedrooms................................ .Expansion Attic ( ) Garbage Grinder ( )
'4 Other—T e of Building No. of persons............................ Showers — Cafeteria
0.' Other fixtures ------------------------------------------•••-
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length--------------_ Width................ Diameter---------------- Depth................
x Disposal Trench—No....................:Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date......................._.................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
rZq Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
a --•-------••••--••••••••••---••••-••••••--•------•-•-•••..............•-------•...-----••-•••--•--••.........................................................
0 Description of Soil--------------------------------................................................------------------------------------------------------------------------------------....
x
U -•••-•-•---•--••--•••-•...---•-•---•-•-------------------•----...........-•-----•--------------•---•--•--------•-•-••••--•-•-•-••--••-•••-------------•••--•---•-------•----------------•-.............
Z -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•--
V Nature of Repairs or Alterations—Answer when applicable____ �� ____ 11 � ..
.......... .......... .f . .—QrrI.a-------------------------------------------------------------•----...------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE •5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance as en issue by he board of h alth.
Signed ---- --- ------ ......... .._. --- ....... ----` ----------- ........ ®- 9
ApplicationApproved By --- ------- ------------ -- ------ ...... ..........................................................
Dace
Application Disapproved for the following re ns- .......... --------------- ................................------......................................................
--...----------------------------------------- ..... ...... .....................----------------.....................................-----Date...... .........................---------------
Date
PermitNo. .... . ------------------ Issued ........ . ............................................---------------
t�
_�'�
No. �,. _...__...�. Fss _....._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliration for Disposal Works Tonsirnriion Prrmit
Application is hereby made for a Permit to Construct ( ) or Repair (5,,/) an Individual Sewage Disposal
System at:
•--�` ` __GG - - �n1 n1 .�....._..---•----- �.�1rt)GU��. .��
-------------------------
Location-Address /� - or Lot No.
o�w�ner Address
Installer Address
UType of Building Size Lot s.41- ---d.=...Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
'4 Other—T e of Building No. of persons---------------------------- Showers — Cafeteria
Otherfixtures -------------------------------•-------•--------•--------------------2----------•-------•-•---------------------------•-------------•--------------.
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank-Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area_...................sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
z Other Distribution box ( ) Dosing tank
Percolation Test Results Performed by------- ---------'------------ ------------------------------------------ Date........................................
a � �
Test Pit No. I................minutes per inch Depth of Test Pit__1----------------- Depth to ground water-____________---__---.-.
(s, Test Pit No. 2................minutes per inch -Depth of Test Pit-_-....__._.._.___ -Depth to ground water........................
G�i I. �-
- \ t-_)\ --.. ---------------------------------------------------------------------
ODescription of-Soil-•---------------------------------------------------.-•-_.....\7.............---------------------------------.......-----...-----------------------------------•----
",� _.."
W ----•------------------------------------•--•------------------------------------------...----•----•------------•---------------------------•----==••------•-------...-----------•------•---•-----------
UNature of Repairs or Alterations—Answer when applicable...../2"-�-"4.�94A.<., ......
Agreement: '"
The undersigned agrees-to install the aforedescribed Individual-Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance as en issue by he board of;h alth.
..--- ----�- ..... ---- --------------
Signed ..--- - ---------- --
C to
Application Approved BY -----�..--��/ -��-' --- ---- - . -------•------ ----------------------------------------------------- ------ ----��----h--�
Date
Application Disapproved for the following re ns- ----------------------------------.........-------------------- ........................--------. ...-----------............
------------------------------------- .... ............... -.................
---'-----------. ---------.--...-..-..-- -'---.........-....-..............-.....................................----'---Dace.. .-----
Dare
Permit No. . ............... Issued
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Tertiftrate of Tontyliaxi.CP
r
THIS IS TO CE IFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (_1<1 )
Installer '�
at1—�.. ZJI/U�11-��'------...� ..... ... 'v ..
-----------
has been installed in accordance with the provisions of TITLE 5 of The S to Environmental Code sdribed in
the application for Disposal Works Construction Permit No. ...9.(� .... .. .....7..... dated /;.... .... Q------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARA TEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. r
DATE..............................s -' 1 t
... Inspector ----------------------------------------.......................................................
i
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
f�s TOWN OF BARNSTABLE
No .t�l..--..... ..� FEE... •-•-------
Disposo1 Works Tons#rur#ion Prrmit
Permission is hereby granted. �:.....................
...............
to Construct ( ) or Repair (,kj an Individual Sewage Disposal System
atNo. .............. ld..-----•-•-7 ....................... ---•----•--•--•--•• /_... ---•--
Street I
as shown on the application for Disposal Works Construction P mi NO— aed..- Q ��19�
j� 0Board of Health
DATE............ ......................
FORM 36508 HOBBS♦!t WARREN.INC..PUBLISHERS
E L-O W PROFILE ALL PIPE ELEVATIONS SPECIFIED ARE INVERT ELEVATIONS VENT
EXPRESSED IN DECIMAL FEET NOT FEET AND INCHES. PIPE
TOP OF FOUNDATION RAISE COVERS TO WITHIN SIX INCHES OF FINAL GRADE
EL = 39.09 +- ONE INSPECTION RISER FOR
LEACHING GALLERY
o �/
3F.50
D-BOX 3 Ft
3- DROP MAX
FLOW LINE - =7 TEE 34.50
10 - � =--:
14'
>,�
46" GAS�� PRECAST
BAFFLE DRYWELL
\34.101F- 6 in BOTTOM OF
STON LEACHING SOIL ABSORPTION
EXISTING 33.68 SYSTEM
EXISTING BASE GALLERY
EXISTING 34.05
EXISTING 33.75 (END VIEW) 31.7s 5.00 Ft +
1500 GALLON
SEE DETAIL ON REVERSE
EXISTING SEPTIC TANK 3 Ft e) 4.5 f t 12.5 ft
61 12 f t
ADJUSTED 16.30
SEASONAL HIGH
CO rn GROUNDWATER
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C. ULATIONS
SOIL TEST LOG D E S I G N C /� L�
DATE OF TEST: MAY 22.' �fiO06 DESIGN FLOW: 4 BEDROOMS X 110 GPD = 440 GPD
SOIL EVALUATOR: DAVID D. COUGHANOWR, R.S.
WITNESS REOUIREMENT WAIVED - NO VARIANCES SOUGHT SEPTIC TANK: 440 GPD X 2 DAYS = 880 GALLONS
NO GROUNDWATER ENCOUNTERED USE EXISTING 1500 GALLON SEPTIC TANK IF IN SOUND STRUCTURAL
CONDITION. IF NOT. INSTALL 1500 GALLON SEPTIC TANK (MINIMUM ALLOWED)
TEST PIT 1 PARENT MATERIAL: PROGLACIAL OUTWASH
ELEVATION = 36.70 +- PERC RATE: 2 MIN/INCH IN C SOILS DISTRIBUTION BOX: USE 3 OUTLET D-BOX.
SOIL ABSORBTION SYSTEM: A 33.5 Ft x 12.5 Ft x 2 Ft- LEACHING GALLERY CAN LEACH
DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER A b o-L = (3 3.5 x 12.5 ) = 418.7 5 s F
(INCHES) HORIZON TEXTURE (MUNSELL) MOTTLING A s d w = ( 3 3.5 + 3 3.5 + 12.5 + 12.5 ) x 2 = 16 4.0 s F
36.70 Atot = 602.75 sF
0-10 AR SANDY LOAM 10 YR 3/2 NONE FRIABLE V t 0.74 x 6 0 2.7 5 = 446.03 G P D
10-32 Bw LOAMY SAND 10 YR 4/4 NONE FRIABLE USE A 33.5 Ft x 12.5 Ft x 2 Ft GALLERY. Vt = 446.03 GPD .> 440 GPD REQUIRED
34,03
32-120 C MEDIUM SAND 10 YR 6/4 NONE LOOSE
26.70 LEACHING GALLERY CONSTRUCTION
DETAIL 500 GALLON DRYWELL
NO GROUNDWATER ENCOUNTERED SHOREY PRECAST CONCRETE DIMENSIONS AND DETAIL
TEST PIT 2 PARENT MATERIAL: PROGLACIAL OUTWASH 500 GALLON DRYWELL USE H-10 UNIT
ELEVATION 37.00 PERC AT 54 in : 2 MIN/INCH IN C SOILS LEACHING UNIT OR
,�_ EQUIVALENT
S T O N INSTALL ONE INSPECTION
RISER TO WITHIN SIX
INCHES OF FINAL GRADE
DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER 33.5 Ft ONOAS-BUILT INDICATECARD.
LOCATION
(INCHES) HORIZON TEXTURE (MUNSELL) MOTTLING m
37.00
0-12 Ap SANDY LOAM 10 YR 2/2 NONE FRIABLE e 0 34
Lo O O OLo
12-38 Bw LOAMY SAND 10 YR 4/4 NONE FRIABLE N N �0���0
33.83
38-138 C MEDIUM SAND 10 YR 6/4 NONE LOOSE
0
25.50 4.0 8.5' 8.5- 8.5' .0. Gjg
33.5 f t 10Z to
NOTES LEACHING GALLERY
CROSS SECTION VIEW
USE SHOREY PRECAST 500 GALLON LEACHING DRYWELL (H-10 LOADING)
1) GARBAGE GRINDER NOT ALLOWED WITH THIS DESIGN 2 te17
PEASTONE 2 In PEASTONE
2) ALL LINES TO BE SCH 40 PVC AND PITCH AT 1/B INCH PER FOOT MINIMUM.
3) ALL COMPONENTS INSTALLED SHALL MEET THE MINIMUM REOUIREMENTS 0
OF MASSACHUSETTS TITLE 5 SEPTIC CODE (310 CMR 15) 28 24 in 3/4 to TO 2EFFECTIVE4) INSTALLER TO VERIFY LOCATIONS OF ALL UNDERGROUND UTILITIES 1n DEPTH 1-1/2 to GRAVEL In
BEFORE EXCAVATING FOR SYSTEM.
5) EXISTING LEACHING GALLERY TO BE REMOVED -
46 to 58 to 46 to
6) ALL STONE TO BE DOUBLE WASHED AND FREE OF IRON, FINES AND DUST IN PLACE
7) LINES EXITING D-BOX TO RUN LEVEL FOR 2•-0- BEFORE PITCHING DOWN 150 to
8) ECO-TECH ENVIRONMENTAL RECOMMENDS THE INSTALLATION OF LOW FLOW FIXTURES
AND APPLIANCES. AND BIANNUAL PUMPING OF THE SEPTIC TANK
9) SYSTEM IS NOT DESIGNED TO WITHSTAND VEHICULAR LOADING-%IDO NOT GROUNDWATER ADJUSTMENT SEWAGE DISPOSAL SYSTEM PLAN
PARK OR DRIVE VEHICLES OVER SEPTIC SYSTEM. r?�
101 INSTALLER TO OBTAIN DISPOSAL WORKS PERMIT BEFORE STARTING WORK. EXISTING GROUNDWATER LEVEL
� BASED ON TOWN of eARNSTABLE -TO SERVE EXISTING DWELLING
11) SEPTIC TANKS SHALL BE INSTALLED LEVEL AND TRUE T.O. GRADE ON A LEVEL GIS DEPARTMENT RECORDS.
STABLE BASE THAT HAS BEEN MECHANICALLY COMPACTED`-ANDjON-__TO WHICH RALPH T. DEWOLFE
SIX INCHES OF CRUSHED STONE HAS BEEN PLACED-:PTO MINIMI-ZEf UNEVEN SETTLING INDICATED GW 14.00
INDEX WELL SDW-253 134 OLD TOWN ROAD HYANNIS. MA
12) SEPTIC TANK TO BE PUMPED DRY AT TIME OF SYSTEM REP,AIR,/AND CHECKED ZONE B
FOR STRUCTURAL INTEGRITY. INSTALL PVC OUTLET TEE; FITTED WITH GAS BAFFLE. READING DATE MAY. 2004
READING 48.1 ECO-TECH ENVIRONMENTAL
ADJUSTMENT 2.3
ADJUSTED GW 16.30 43 TRIANGLE CIRCLE SANDWICH MA 02563
ETE-2356 JUNE 21. 2006 2/2