HomeMy WebLinkAbout0009 QUISSET ROAD - Health (2) 9 QUISETT RD., CENTERVILLE
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UPC 12534
No.2_3_ �„�,,,e
MAITINa8, YN
a,,,,,TOWN 9BARNSTABLE N
LOCA711ON I SEWA L%# s
VILLAGE �Sl/1 1 ASSESSOR'S MAPCC.•& LO
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size) �o00
NO. OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: COMPLIANCE
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility (If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
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ADgo
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YOU WISH TO OPEN A BUSINESS?
For Your Information: Business certificates (cost$30.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which
you must do by M.G.L.-it does not give you permission to operate.) Business Certificates are available at the Town Clerk's Office, 1"FL., 367
Main Street, Hyannis, MA 02601 (Town Hall)
DATE: AAUST o90t ?alb Fill in please:
APPLICANT'S YOUR NAME/S: (Y1ZU
,t,� 'F✓ � `' € BUSINESS YOUR HOME ADDRESS: 1 C�Z63L,
TELEPHONE # Home Telephone Numbers " 7 "Y
NAME OF CORPORATION: . '14C 5—iAt4 i Eelt S T-
NAME OF NEW BUSINESS `1 N e -;5T0'X tC-Ci%S r TYPE OF BUSINESS �S t>-UG v VVWff
IS THIS A HOME OCCUPATION? YES NO d� -bftC.,ES c tAM
ADDRESS OF BUSINESS—A Q y�SSt`s 9-2:5 LA y-Z(6,3 2 MAP/PARCEL NUMBER J ��' (Assessing)
When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of
Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth
Rd. & Main Street) to make sure you have.the appropriate permits and licenses required to legally operate your business in this town.
1. BUILDING COMMISSIONER'S OFFICE
n in
This individual has be formed y permit requirements that pertain to this type of businessMUST COMPLY WITH HOME OCCUPATION
RULES AND REGULATIONS. FAILURE TO
uthorize Sign ure** CO LY AY RESULT IN FINES,
COMMENTS: a G�.
2. BOARD OF HEALTH
This individual has f rmed Wmitrereme t-pertain to this type of business.
Authorized Signat e** MUST COMPLY WITH ALL
COMMENTS: HAZARDOUS MATERIALS REGULATIONS
3. CONSUMER AFFAIRS (LICENSING AUTHORITY)
This individual has been informed of the licensing requirements that pertain to this type of business.
Authorized Signature**
COMMENTS:
YOU WISH TO OPEN A BUSINESS?
For Your Information: Business certificates(cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you
must do by M.G.L.-it does not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St., Hyannis.
Take the completed form to the Town Clerk's Office, 1st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is
required by Law.
DATE: -)3 20 i`Z. Fill in please:
APPLICANT'S YOUR NAME/S: Al( IL -- i�F�n c S
r BUSINESS / YOUR HOME ADDRESS: G2v`,s5 -r 6z�J C�rv2�� (� OZ-to —
TELEPHONE #. Home Telephone Number O — 7 —5 Co if
NAME OF CORPORATION:
NAME OF NEW BUSINESS 'f')0 r E TYPE OF BUSINESS t t�Q, `T' 5 i130L-O&J-6 S
IS THIS A HOME OCCUPATION? YES NO `� D )sC�
ADDRESS OF BUSINESS c v�55� N � �� t MAP/PARCEL NUMBER 0 (Assessing)
When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of
Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth
Rd. &Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town.
1. BUILDING COMMISSIONER'S OFFICE
This individual has been informed of any permit requirements that pertain to this type of business. .
Authorized Signature*
COMMENTS:
2. BOARD OF HEALTH
This individual has lbe r en Mthe permit requirements that pertain to this type of business.
Authorized Signature*
COMMENTS:
3. CONSUMER AFFAIRS(LICENSING AUTHORITY)
This individual has been informed of the licensing requirements that pertain to this type of business.
Authorized Signature*
COMMENTS:
,l'•:y
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS John Grad
DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector
ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119
TeaTicket,Ma.
(508)564-6813
TRUDY COXE
Secretary
ARGEO PAULCELLUCCI DAVID B.STRUHS
Govemor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 9 QUISETT RD. CENTERVILLE c7 cJ L 3
Name of Owner STEINBERG t
Address of Owner: 917 SALEM ENDS RD.FRAMINGHAM MA.01702
Date of Inspection: 9/22/99 c
Name of Inspector:(Please Print)JOHN GRACI 40 �C V
f am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) S cp IT
Company Name: n/a < 2 9
Mailing Address: n/a % A0100P N 1999.
Telephone Number: n/a �Ot T Z,
A�` `• '
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate
and complete as of the time of inspection.The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems.The system:
X Passes The inpection is based on criteria defined In Title V
Conditionally Passes code 310 CMR 15.303.My findings are of how the system Is
Needs Further Evaluation By the Local Approving Authority performing at the time of the inspection.My inspection does
_ Fails not imply any warranty or guarantee of the longgevity of the
septic system and any of its components useful life.
Inspector's Signature: Date:9/23/99
The System Inspector shall#ubmita copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(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 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
THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING THE SYSTEM EVERY TWO YEARS TO PROLONG THE SYSTEM'S
USEFULL LIFE.
revised 9/2/98 Page 1 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 9 QUISETT RD.CENTERVILLE
Owner: STEINBERG
Date of Inspection:9/22/99
INSPECTION SUMMARY: Check A, A C, or 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 below.
COMMENTS:
System passes Title V inspection
B. SYSTEM CONDITIONALLY PASSES:
nLa 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.
Wa The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance(attached)indicating that the tank was installed within 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.
nta Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
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
n1a 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 2 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 9 QUISETT RD.CENTERVILLE
Owner: STEINBERG
Date of Inspection:9/22/99
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 described in 310 CMR 15.303.The basis for this determination is
identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool.
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow,
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped Wa.
X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool or privy is within a Zone I of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well,
X Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality
analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic ompounds,
ammonia nitrogen and nitrate nitrogen.
X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure.
E. LARGE SYSTEM FAILS:
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:
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 because one or more of the following conditions exist:
Yes No
X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary to a surface drinking water supply
X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-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 15.30412).Please consult the local regional office of the
Department for further information.
revised 9/2/98 Page 4 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 9 QUISETT RD.CENTERVILLE
Owner: STEINBERG
Date of Inspection:9/22/99
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.
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 AND SAFETY AND THE 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 soil 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 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,Method used to determine distance »La_(approximation not valid).
3) OTHER
t1L3
revised 9/2/98 Page 3 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 9 QUISETT RD.CENTERVILLE
Owner: STEINBERG
Date of Inspection:9/22/99
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
Yes No
X Pumping information was provided by the owner,occupant,or Board of Health.
X 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.
X As built plans have been obtained and examined.Note if they are not available with N/A,
X The facility or dwelling was inspected for signs of sewage back-up.
X The system does not receive non-sanitary or industrial waste flow.
X The site was inspected for signs of breakout,
X All system components,excluding the Soil Absorption System,have been located on the site.
X 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:
X Existing information,For example,Plan at B4O,H,
X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)
(1 5.302(3)(b)1
X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of
SubSurface Disposal Systems.
revised 9/2/98 Page 5 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 9 QUISETT RD.CENTERVILLE
Owner: STEINBERG
Date of Inspection:9/22/99
BUILDING SEWER:
(Locate on site plan)
Depth below grade: 1L
Material of construction:_ cast iron X 40 PVC _ other(explain)
Distance from private water supply well or suction line: TOWN
Diameter: nLa
Comments: (condition of joints,venting,evidence of leakage,etc.)
nta
SEPTIC TANK: X
(locate on site plan)
Depth below grade: V
Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain)
nta
If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): DLO
Wa
Dimensions: L 8'6"H 5'7"W 4'10"
Sludge depth: 2
Distance from top of sludge to bottom of outlet tee or baffle: 3r
Scum thickness:1
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: 17"
How dimensions were determined: MEASURED
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.)
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND RECOMMEND PUMPING EVERY TWO YEARS.
GREASE TRAP:
(locate on site plan)
Depth below grade:
Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain)
n/A
Dimensions: nLa
Scum thickness: nLa
Distance from top of scum to top of outlet tee or baffle:i3La
Distance from bottom of scum to bottom of outlet tee or baffle n/a
Date of last pumping: nta
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.)
Wa
revised 9/2/98 Page 7 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 9 QUISETT RD.CENTERVILLE
Owner: STEINBERG
Date of Inspection:9122/99
FLOW CONDITIONS
RESIDENTIAL:
Design flow:-=g.p.d./bedroom
Number of bedrooms(design): 3 Number of bedrooms(actual):I
Total DESIGN flow: =
Number of current residents:A
Garbage grinder(yes or no):YES.
Laundry(separate system)(yes or no): NO If yes,separate inspection required
Laundry system inspected(yes or no):M
Seasonal use(yes or no): YES
Water meter readings,if available(last two year's usage(gpd): nLa
Sump Pump(yes or no): NQ
Last date of occupancy: nLa
COMMERCIAL/INDUSTRIAL
Type of establishment: nLa
Design flow: Wit gpd(Based on 15.203)
Basis of design flow: Wit
Grease trap present:(yes or no):M
Industrial Waste Holding Tank present:(yes or no): KQ
Non-sanitary waste discharged to the Title 5 system:(yes or no):NQ
Water meter readings.if available:Wit
Last date of occupancy: iota
OTHER: (Describe)
Wa
Last date of occupancy: Wa
GENERAL INFORMATION
PUMPING RECORDS and source of information:
nLa
System pumped as part of inspection:(yes or no):NQ
If yes,volume pumped nta_ gallons
Reason for pumping: nA
TYPE OF SYSTEM
X Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no)(if yes.attach previous inspection records,if any)
I/A Technology etc.Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other: Wa
APPROXIMATE AGE of all components,date installed(if known)and source of information:
1983 PERMIT#1983-374
Sewage odors detected when arriving at the site:(yes or no): NQ
revised 9/2/98 Page 6 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 9 QUISETT RD.CENTERVILLE
Owner: STEINBERG
Date of Inspection:9/22/99
TIGHT OR HOLDING TANK: NQ (Tank must be pumped prior to,or at time of,inspection)
(locate on site plan)
Depth below grade: n&
Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain)
nLa
Dimensions: n/a
Capacity: nLa gallons
Design flow: nLa gallons/day
Alarm present: NQ
Alarm level:j]L& Alarm in working order:Yes—No—: NO
Date of previous pumping: Wa
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
Wa
DISTRIBUTION BOX: X
(locate on site plan)
Depth of liquid level above outlet invert:LIQUID ID VEL WITH BOTTOM OF PIP
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.)
DISTRIBUTION BOX IS STRUCTURALLY SOUND,SYSTEM IS FUNCTIONING PROPERLY
PUMP CHAMBER: NQ
(locate on site plan)
Pumps in working order:(Yes or No): NQ
Alarms in working order(Yes or No): NIQ
Comments:
(note condition of pump chamber,condition of pumps and appurtenances.etc.)
nLa
revised 9/2/98 Page 8 of 11
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 9 QUISETT RD.CENTERVILLE
Owner: STEINBERG
Date of Inspection:9/22/99
SOIL ABSORPTION SYSTEM(SAS): X
(locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods)
If not located,explain:
nLa
Type:
leaching pits,number: 1000 GALLON LEACH PIT
leaching chambers,number: _nLa
leaching galleries,number: jjLa
leaching trenches,number,length: nla
leaching fields,number,dimensions: n&
overflow cesspool,number: nLa
Alternative system: n&
Name of Technology: -n&
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.)
THE LEACH PIT APPEARS TO BE FUNCTIONING PROPERLY,SYSTEM SHOWS NO SIGNS OF FAILURE.
CESSPOOLS:
(locate on site plan)
Number and configuration: nLa
Depth-top of liquid to inlet invert: Wa
Depth of solids layer: WA
Depth of scum layer. iQ
Dimensions of cesspool: Wa
Materials of construction: nLa
Indication of groundwater: Wa inflow(cesspool must be pumped as part of inspection)Wa
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
nLa
PRIVY: _
(locate on site plan)
Materials of construction:n& Dimensions:nLa
Depth of solids: n&
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
Wa
c
revised 9/2/98 Page 9 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 9 QUISETT RD.CENTERVILLE
Owner: STEINBERG
Date of Inspection:9/22/99
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)
n/a
I 644 __&
c � �
1) F1 6 J
0
A635
G
A-0
�c 5�
Rt,L
revised 9/2/98 Page 10 of 11
' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 9 QUISETT RD.CENTERVILLE
Owner: STEINBERG
Date of Inspection:9/22/99
NRCS Report name: nLa
Soil Type: n&
Typical depth to groundwater: Wa
USGS Date website visited: Wa
Observation Wells checked: N-Q
Groundwater depth:Shallow _ Moderate _ Deep _
SITE EXAM _ Slope
_ Surface water
_ Check Cellar
_ Shallow wells
Estimated Depth to Groundwater 12 Feet
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
XUsed USGS Data
Describe how you established the High Groundwater Elevation.(Must be completed)
USGS MAPS AND CHARTS
revised 9/2/98 Page 11 of 11
1,0.tATION SEWAGE PERMIT NO.
VILLAGE
INSTALLER'S NAME ADDRESS
e ke<�,
e U I L D E N OR OWNER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED /� r,
i 1
LL Q. t
„4
�1
0
ti
•
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
Tow$n............-----OF....i.3.AAV.STO-la-I,F-.._....------..............._...
Appliration for Di-goiial Works Tonutrurtion Vanfit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
.......L�+ ., .... - ..._ _9.�.1 ...................
Location-Address ox Logy No.
Owne_, Address
j ►� . -.............. ----------------------------------------------------------------------------------------•-------..
Installer Address
Type of Building Size Lot..;.29`Q0!�...... ee
V Dwelling—No. of Bedrooms___..______________ Expansion Attic ( ) Garbage in r
Other—Type e of Building No. of persons............................ Showers — Cafete is
a YP g P ( ) ( )
a Other fixtures .................................
W Design Flow............................................gallons per person per day. Total daily flow.....33 ..........................-gallon
WSeptic Tank—Liquid capacityl�_.gallons Length................ Width---------------- Diameter---------------- Depth-_ �.�e(' +
x Disposal Trench—No.. ................. Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No-__.._.I------------- Diameter..4�____- Depth below inlet.................... Total leaching area...A_44_....sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
,4a Test Pit No, 14J.......minutes per inch Depth'of Test Pit.................... Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
R; ------------•--• • ------••-- •-----.....-____-•_-__-_•y__--__------- ......
0 ----- --
O Des iption of 'Soil ... `r ®� ® 1---- -� �-•.......� .............................
x c _ r�c.......„�
x --•-•-•----•------•------------••---•-•---------•-•-----------------------•--•---•--••--••......---•--------. �.
U Nature of Repairs or Alterations—Answer when applicable._.._... ........ .......................:.........................................
-------------------------------------------------------------------------------------------•_••-•-•--••-••-••-•---------•--•-•-------•----------------••---•----•-•••----••••--------•••------••----•-.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Di sp 1 System in accordance with
the provisions of TITI.L 5 of the State Sanitary Code— The undersigne furthe grees not to place the system in
operation until a Certificate of Compliance has be sue he boar healt .
Sig d ? '--- •---•-------------•---•••--•-•---•-----•-•--- .. ... _�
�D e
Application Approved By..:lefol�lowing
' ........................
S� �'�
Date
Application Disapprove or reasons:
.......................................----------••-------•----•--------...-•--•----•-----••---•--•-•-•---•-----•-------•--••-•-•-•---•------------------••-•----------••------------•-------• ......
Date .
PermitNo......................................................... Issued................................................•-------
Date
T3o. -T..F....... Fps. ...............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
L_.Q. .d ................OF.....
� .> .x .. ��-�4•
Apphratiun for Dispos al . urks Tonstrurtiun ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
's. a.1!5% t!1 . .. '�_t/1��'I^-+� ����x..... ......................................
Location-4ddress or Lot No.
' i
=•�� ..._ a" ........................................ .......
Owner Address •[
.............• ---...._._.._._._..---------•-•-•----•--.._...-•--•--...__...-----...---..................--------
Installer Address
U Type of Building Size Lot._ ?` >. �)inS
Dwelling—No. of Bedrooms.......r"�............_...................Expansion Attic ( ) Garbage G-Other—Type of Building ____________________________ No. of persons__.______._.___________...._ Showers ( ) — Caf
Otherfixtures --------------- •-••--------••---------•--...-----•-•-•------._._..__...----•----•-•------••---•-•------•-•-•---...--•-
----------------
W Design Flow............................................gallons per person per day. Total daily flow------ ..........................gallons
WSeptic Tank—Liquid*capacity W_gallons Length................ Width................ Diameter................ Depth_. Zp__.:ft'_c',-a5f
x Disposal Trench—No_ ____________________ Width...............:.___ Total Length.................... Total leaching area_...................sq. ft.
Seepage Pit No____________________ Diameter_.Z .._. Depth below inlet.................... Total leaching area... �Al`....sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. l<._ .....minutes per inch Depth of Test Pit____________________ Depth to ground water........................
0-4
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
--•----•• ----- -------------------------••-•--•----------_....---
Des iption of Soil • ......... S t7 ----•-- -
----•--------------------- -------------------------------------------------------------•--------------------- -------- -----...............
U Nature of Repairs or Alterations—Answer when applicable...._•.;f. __ , ____ ..............................................................
................................-•-----------------------------------------------------------------------------•-•--•---------•-•
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Dispopal System in accordance with
the provisions of TITiZ 5 of the State Sanitary Code— The undersigne further grees not to place the system in
operation until a Certificate of Compliance has bee i sued e boar -lealt .
Sig ---.
�D; o
Application Approved By _ . Q-----._...-•................................................•---•-----•• -.... ''�- � -_-----
Date
Application Disapproved or. e following reasons:-------•----------------------••----•---•..------------•--------------------------------------------------------
---•--•--------------------•-----•----------••----•••---•----...-•--•••-•------.......__....--•-••-----•-•------------------------•-•-••----------•---•-••-•-••--•------••-------•••----••••-----•-•--•-
Date
PermitNo................•------------••-•------....--------•---. Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEA TH
. 0L4... .rr. .................OF.......� � .' .. ....._ .. . ..................................
Tatifiratr of Tuntphatt r
TH 0 CE Y, That th v Sewage Disposal System constructed ( ) or Repaired ( )
by... .............---•• •-....... --- --------------------------------•-----•--------•----____----•------••----•--•---•---•••--
Installer
at............... = = -•---------------------•----•----...-•-•----•------------------------.-.-----•----------------------------
------/UARANTEE
------------
has been install d in ccordance with the provisions of T[5 5 of he State Sanitaryd r d in the
application for D osal Works Construction Permit No___________ _ t��_.____________. dated-. __ _- ................
THE ISSIJANC OF THIS CERTIFICATE SHALL NOT BE CONSTR D AS A THAT THE
SYSTEIOeI/1dYl F CTION SATISFACTORY.
DATE b_ . ..% ......... Inspector... ....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.OF.......................................................•-•......._._..___..._....._.. �!
� ... FEE.........................
Rapuod-- r f,�unstrurtiou rrmit
Permission is he y granted_.. -• -•--• -- - _•• ••-------------•-•- -----------------------------------
.................
•-•• ......---
to Constr��LY Repair ( n Individua ' ystem
at No..... ----- ..._...
l Street — -- - ....
as shown on the application for Disp sal Works Construction Permit No---_---_---------- Date ...":.....__
....................................... Boar He---------- -- ---------------------------------------
f
DATE......................................[�-/ .__21,?2---------------• g+ ^'�
FORM 1255 HOBBS & WARREN. INC., PUBLISHERSi fps
S/TTE PL A N T YPICAL PROFIL E
SCALE -- / = �� �.<� �_ ,
NOT TO SCALE
/8"STD. L T. WG T C./. MH COVER
7
4"C.l P'PE 7 4"BIT FIBER PIPE TIGHT JOINTS
._'�
OUTLET LEVEL
FLOW LINE O O Tp_�ST ✓O/NT7 - — —-
DWEL LING I o— lO" --�--
% C.1. rEE C. TEE
60•41
STANDARD PRECAST 4 r-- .---
CONCRETE f GO-GAL LON ��j• '^j O J I
-. -` SEPTIC TANK - �
- - _--- DlS TR/BU TION BOX I
TO BE INS rAL L ED ON
LEVEL , STABLE BASE.
SEPTIC TANK
TO BE INSTA L L EC ON
I- c T Lo LEVEL , STABLE BASE
CL L7 5v�
2"- //B" rO //2" WA SHED PEA STONE t EfI CHI NG PIT
ALL AROUND FREE OF IRONS, FINES BA f TO BE L EVF-L
h tz v :✓ a u i AND DUS T /N PL ACE
la rt �. too • , rr K P - BRICK 61 MORTAR COURES •,
* -�• - -L 4
E T ��I TP, ,�! �,` . AS RFOUIRED TO BRING
3/4' TO l //2 WASHED CRUSHED
COVER TD GRADE 24"C I. MH COVER STONE ALL AROUND FREE OF
IRONS, FINES AND DUST /N PLACE.
A ND FRA M£
ST flox j
G
'y -4„
INLET � -� '`. `8' FLOW L/NE r _ _r_ _ LEACHING PIT SECTION-
-
PIPE -- --- —� ! -- --� - ! CONCRETE TO BE 4000 PSI 28 DAYS
2 REINFORCED WITH 6' x 6" N0 6 GA. W.W M
Il 3. 2• AND 4' SECTIONS ARE AVAILABLE FOR .GREATER
iL w j , DEPTH REQUIREMENTS.
OPENING WITH 4-//6' { 4 NUMBER OF PITS REQUIRED
OUTER DIAMETER 8 NOTE. EXCAVATE TO ELEVATION 5°'`oOR LOWER AS
I-3/4" INSIDE DIAMETER I
REQUIRED TO REMOVE ALL LOAM AND CLAY BENEATH
PIT REPLACE. EXCAVATEC MATERIAL WITH CLEAN
1�j 4-PIT + GRAVEL_ TO DESIGNED GRADE
EL G G• �'
C
�-oT
4, 0,. 6'- 6
EFFECriVE DIAMETER
(NOT TO EXCEED 3 TIMES EFFECTIVE DEPTH)
WATER TABL E
4 ki, N e. 1r v hi j Cc rz r D)
SOIL t=;ND PERC. DATA GENERAL NO TES -
_ PERC• RATE MIN. /IN . NO HEAVY EQUIPMENT TO RUN OVER SYSTEM.vJ a � LJ A- c? u T L � SEPTIC TANK, DISTRIBUTION BOX , LEACHING PITS TO BE STANDARD
I( 40` Pv F-mbL-, <- `�� >�Y ) TEST BY: ��-�M ' A I2`U IG G- ¢ PRECAST REINFORCED CONCRETE UNITS
WITNESSED BY le-UtiJ U tr-FofzV 0 0. N ALL SYSTEM COMPONENTS SHALL BE INSTALLED IN ACCORDANCE
TO REVISED TITLE 5 OF THE STATE ENVIRONMENTAL CODE ,
TEST PIT GR EL. - a DATE ' 4 2---)f 4�z MINIMUM REQUIREMENTS FOR THE SUBSUFACE DISPOSAL OF
TEST PIT NO. I r- I-)I tj TEST PIT NO. 2 Fes- 1 14 SANITARY SEWAGE EFFECTIVE I JULY 1977.
0 �Li�;o0"T ANY CHANGES TO THIS PLAN MUST BE APPROVED BY THE
ory LOAM ,� TvP/Sd0oIL
GLA`(E -( ��Ia5)9IL — BOARD OF HEALTH.
- c v A szg r� AT COMPLETION OF CONSTRUCTION , PRIOR TO BACKFILLING, THE
EL &0,o
e,tiC> BOARD OF HEALTH SHALL BE NOTIFIED FOR INSPECTION.
PITCH ALL SEWER LINES 1/4" / FT. UNLESS INDICATED
OTHERWISE.
AlO w TFdat -- - IUo �_/ATeFr_
DESIGN DATA
BEDROOMS DISPOSAL Ij
EST. TOTAL DAILY EFF. 2-L2 GALS.
LEGEND - SEPTIC TANK Ivor GAL.
- _ SiDEWALL AREA — Z"5 GAL./SO. FT
OXOO EXISTING GRADE
BOTTOM AREA __ I ' 0 GAL./SO. F? 171
LEACHING REQUIRED -SO FT,
JEII'f/AVE DISPOSAL SYSTEM
�`�� ��
70NE fz y _.! o 0o FINISHED GRADE ACTUAL LEACHING AREA SQ.FT. I 1�
`ram �cJ rJ w A T F_ ►:Z —O . aU INVERT ELEVATION %/jvZ� r r'�._' , .,� Tr' •, L - —j t� U T
DOMESTIC WATER SOURCE i �Q U ^Qy T
- - PROPERTY LINE ' 'r( LrtiTr12V, i,-L- E r:,,,AaIj 7A0L_ eI NA A.
� PLAN REFERENCE —______ __
-- - MEAN HIGH WATER SCALE: AS INDICATED DATE `� ion ` ->
I - -
r
R BENCH MARK DATUM _ r ±��'� y �' `' Tv r'p '=_ w_ �- MARSH WM M WARWICK & ASSOCIATES
t
r- L v v >7 7- o r-J E til o ry - N A z A tz p BOX 8C�1 - NORTH FAL,NOLI TH
Ml'SSACHUSE T T" 025 56