Loading...
HomeMy WebLinkAbout0089 CHERRY TREE ROAD - Health Ct Ch2rr� ee Po � (COTUIT) - A= i COMMONWEALTH OF MASSACHUSETTS , EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS Z DEPARTMENT OF ENVIRONMENTAL PROTECTION y TITLE 5 � OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS }p.. SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A �' F _ CERTIFICATION ' C, Property Address: 89 CHERRYTREE RD COTUIT,MA 02635 M018 P012 ,r Owner's Name: RICHARD CAIN .k Owner's Address: BOX 454 HARWICHPORT MA.02646 Date of Inspection: 3nloi 1 - Name of Inspector: (please print) 30HN GRACI ' it ,, X,.. Company Name: SEPTIbINSPECTIONS Mailing Address: P.O. BOX 2119 TEATICKET,MA.02536 r Telephone Number: 508-564-6813 FAX 508-564-7270 1R�! CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is = , a,}' true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and,maintenance of on site sewage disposal systems. I am a DEP approved system g P Y pP Y �:.. inspector pursuant to Section 15.3404of Title 5(310 CMR 15.000). The system: X Passes _ Conditionally,Passes t. _ Needs Furqij Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: 3/7/01 thinThe system inspector shall submit copy of this inspection report to the Approving Authority(Board of Health or DEP)wi 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be i sh f x. sent to the system owner and copies sent to,'the buyer,if applicable,and the approving authority. .0.1 Notes and Comments _ THE SYSTEM PASSES TITLE V INPECTION. RECOMMEND PUMPING SYSTEM EVERY TWO YEARS TO a PROLONG THE SYSTEM'S.USEFULL LIFE. (,` ': ,. ****This report only describesPconditions at the time of inspection and under the conditions of use at that time.This inspection does not address how;.the system will perform in the future under the same or different conditions of use. Titlr 5 Incnrrtinn Rnrm r,/it/,?nn6, I r Page 2 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM a PART A CERTIFICATION (continued) F r: Property Address: 89 CHERRYTREE RD COTUIT,MA 02635 M018 P012 ; Owner: RICHARD CAIN °l Date of Inspection: 3/7/01 {i 1 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: tk a . X I have not found any information which.indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: THE SYSTEM PASSES TITLE V INPECTION.RECOMMEND PUMPING SYSTEM EVERY TWO YEARS TO ,k PROLONG THE SYSTEM'S USEFULL LIFE. 1, B. System Conditionally Passes:,. _ One or more system components a's 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. _ j, Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. t':Y n/a The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. T1 , *A metal septic tank will pass inspections if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. t:^ ND explain: n/a n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): _ broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced n ND explain: n/a n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): _broke►-,pipe(s)are replaced <<�" _obstruction is removed -` ' t �t ND explain: n/a 331 r Y e Page 3 of 1 I OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS ° SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART A 'CERTIFICATION(continued) tj'r Property Address: 89 CHERRYTREE RD COTUIT,MA 02635 M018 P012 Owner: RICHARD CAIN Date of Inspection: 3/7/01 C. Further Evaluation is Required by the Board of Health: _ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to r . protect public health,safety or the environment. 1. System will pass unless Board'of Health determines in accordance with 310 CMR 15.303(i)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: - ; _ Cesspool or privy-is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t ` 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the r" system is functioning in a manner that protects the public health,safety and environment: =Mt: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank;"and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank land SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to:,determine distance n/a "This system passes if the well,water analysis,performed at a DEP certified laboratory,for coliform bacteria and rr$:K volatile organic compounds indicates that the well is free from pollution from that facility and.the presence of ammonia ' jA.J%1' g P P h' P �`..lei: nitrogen and nitrate nitrogen is egbal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy 114 of the analysis must be attached to this form. ;; "' S , 3. Other: n/aq. ,• ti.k r' t c u 4 ' E e,i Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS {p' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 89 CHERRYTREE RD COTUIT,MA 02635 M018 P012 " Owner: RICHARD CAIN Date of Inspection: 3/7/01 lf, gt D. System Failure Criteria applicable to all systems: ' t: You must indicate"yes"or"no"to each of the following for all-inspections: Yes No h > - X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool - X Discharge or ponding of effluent to`the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool 'a - X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool C "below invert or available volume is less than '/Z da flow i uid depth in cess ool is less than 6 b o Y � - X Liquid P P - X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped nia. - X Any portion of the SAS,cesspool or privy is below high ground water elevation. - X Any portion of cesspool or privy.is within 100 feet of a surface water supply or tributary to a surface water supply. x - X Any portion of a cesspool orprivy is within a Zone 1 of a public well. , X Any portion of a cesspool or,privy is within 50 feet of a private water supply well. U` '' - X Any portion of a cesspool or.'privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP i'T certified laboratory,for colform 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 t! less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] `r'fi. (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 ,�t � CMR 15.303,therefore the system fails The"system owner should contact the Board of Health to determine what will be �aM necessary to correct the failure. e� t�W, r: E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) r ttii ' .4F 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 1 - 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 If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered , ?, s , Rq "yes" in Section D above the large syste�it has failed.The owner or operator of any large system considered a significant threat ,iiX � under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner g �lAfh should contact the appropriate regional office of the Department. : s aipe;: l "'!a r d Page 5 of 11 i7 OFFICIAL INSPECTION FORM—NOT FOR VOLUr4TARY ASSESSMENTS > SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM �. PART B CHECKLIST Property Address: 89 CHERRYTREE RD COTUIT,MA 02635 M018 P012 Owner: RICHARD CAIN Date of Inspection: 3/7/01 4 4 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health r;r X Were any of the system components pumped out in the previous two weeks? a' X _ Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspectionju '? X _ Were as built plans of the system obtained and examined?(If they were rot available note as N/A) 1, X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out? .,`' X _ Were all system components,excluding the SAS, located on site ? X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil,absorption System(SAS)on the site has.been determined based on: k° Yes no t"}4iY X _ Existing information. For example,a plan at the Board of Health. , X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is ,; unacceptable)[310 CMR 15.302(3)(b)] S: i 1•, s 5 f' Page 6 of 11 ,k OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM �. PART C a; SYSTEM INFORMATION Property Address: 89 CHERRYTREE RD COTUIT,MA 02635 M018 P012 Owner: RICHARD CAIN441 ' Date of Inspection: 3/7/01 FLOW CONDITIONS ' RESIDENTIAL $ ' Number of bedrooms(design): 4 Number of bedrooms(actual): 4 ` DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 549 �,.YY4�• Number of current residents: 1 Does residence have a garbage grinder(yes or,no): NO t Is laundryon a separate sewage system(Yes or no): NO [if yes separate inspection required] ; Laundry system inspected es or no): NO Seasonal use:(yes or no): NO T'tt Water meter readings, if available(last 2 years usage(gpd)): n/a Sump Pump(Yes or no): NO Last date of occupancy: n/a r-- COMMERCIAL/INDUSTRIAL: Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sgftetc.): n/a '. Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO r-{ Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings,if available: n/a d i ler � Last date of occupancy/use: n/a }' OTHER(describe): n/a y � � GENERAL INFORMATION Pumping Records Source of information: n/a Was system pumped as part of the inspection,(yes or no): NO If yes,volume pumped: n/agallons--How was quantity pumped determined?n/a r . Reason for pumping: n/a _ , .Ek:fit•, TYPE OF SYSTEM �t .-.,S, X Septic tank,distribution box,soil absorption system _Single cesspool r _Overflow cesspool _Privy _Shared system(yes or no)(if yes;attach previous inspection records,if any) `'t _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) N�} _Tight tank Attach a copy of the bEP approval Other(describe): n/a Approximate age of all components,date installed(if known)and source of information: 1986 Were sewage odors detected when arriving at the site(yes or no): NO is d:Ys _"4 A Page 7 of 11 . ;t t NA OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEM INFORMATION(continued) T Property Address: 89 CHERRYTREE RD COTUIT,MA 02635 M018 P012 Owner: RICHARD CAIN F ' Date of Inspection: 3/7/01 ;.i; ; BUILDING SEWER(locate on site plan) at, Depth below grade: 18" Materials of construction:_cast iron X40 PVC_other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): Sri. THERE IS TOWN WATERxti z SEPTIC TANK: X(locate on site plan) .a. Depth below grade: I" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a '. If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 1000G L 8' 6" H 5' 7" Ws4' 10"" Sludge depth: I" r 9 Distance from top of sludge to bottom of outlet tee or baffle:33" * Scum thickness:01 1 t 4 t Distance from top of scum to top of outlet tee or baffle: 6" . 4 Distance from bottom of scum to bottom of outlet tee or baffle: n/a How were dimensions determined: MEASURED x,r v = Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. GREASE TRAP:_(locate on site plan) ` r Depth below grade: n/a Material of construction:_concrete 'metal fiberglass_polyethylene_other(explain): n/a +r Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a ` k Date of last pumping: n/at; Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related41 c to outlet invert,evidence of leakage,etc.): { n/a •' ^j� 'N 43 S f �1 'F pE �a 7 f Page 8 of I 1 :•r OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 89 CHERRYTREE RD COTUIT,MA 02635 M018 P012 Owner: RICHARD CAIN Date of Inspection: 3/7/O1 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) 44 Depth below grade: n/a j Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a K Capacity: n/a gallons ' Design Flow: n/a gallons/day , Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): 3`6 n/a =i C DISTRIBUTION BOX:_(if present must be.opened)(locate on site plan) Depth of liquid level above outlet invert: n/a Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): n/a :E e,;r f PUMP CHAMBER:_(locate on site plan) . s. Pumps in working order(yes or no): NO Alarms in working order(yes or nc):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): I ! n/a e • 4s.'i y x, F ti '{j3 �da r� 'i -4 �y `F' l j v ii; R Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM r' PART C SYSTEMANFORMATION(continued) Property Address: 89 CHERRYTREE RD COTUIT,MA 02635 M018 P012 ,f Owner: RICHARD CAIN Date of Inspection: 3/7/O1 £E SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type 1000 GAL 6'X 6' leaching pits, number: 1 n/a {''r leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a leaching trenches, number, length: Na n/a leaching fields, number: n/a ' n/a overflow cesspool, number: n/a 1 n/a innovative/alternative system t Type/name of technology: Na ' y3� ti r•t 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.THE PIT SHOWS NO SIGNS OF FAILUE. ` ` GPD'S 549 LEACH PIT HAS 2' OF STONE CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): k n/a PRIVY: (locate on site plan) ' Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil,signs'of hydraulic failure,level of ponding,condition of vegetation,etc.): , . n/a a, +T . . Page 10 of I 4. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS \? SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOB e� . PART C \ \ SYSTEM INFORMATION%g(n! 2$ Property Address: p CHERRYTREE RD COTU T MA0 65M018P 12 \\ Owner: RCHARDCAN . T Date of Inspection: 3 loi SKETCH OF SEWAGE DISPOSAL iSYST EM �/t Provide askelho the sewage d9ag syslminldigties to at least two permanent Rf galandmarks«b&hmrks ! $»C a�. Lcaeall wells within 10 feet Locate where PA[!c water supply enters the building. \ ' %K \ <± � . y \�} \/ \�\ !i � \ \\ . � ^ \\ « � «�\ \$\ I . \\� §\ \ A j \ \�� . in > © Page I 1 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 89 CHERRYTREE RD COTUIT,MA 02635 M018 P012 Owner: RICHARD CAIN Date of Inspection: 3/7101 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 12+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a NO Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) YES Accessed USGS database-explain: n/a _ You must describe how you established the high ground water elevation: USGS MAPS AND CHARTS- 12+FEET +� „t 4r�� '5 jx Y fyy . j •hf v: • r f1[dI E0 APR 3 . 2000 7000Ft1AgH hL4L7HOfpTA f COMMONWEALTH OF MASACHUSETTS 4' EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET BOSTON MA 02108(617)292-3500 TRUDY COXE Secretary h . ARGEO PAULCELLUCCI DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 89 CHERRY TREE RD. COTUIT, MA 02635 M018 P012 Name of Owner DAVID MORSE Address of Owner: 89 CHERRY TREE RD.COTUIT,MA 02635 Date of Inspection: 3/31100 Name of Inspector: JOHN GRACI I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: SEPTIC INSPECTIONS Mailing Address: P.O.BOX:2119 TEATICKET,MA.02636 Telephone Number: 608-564-6813 FAX 608-664-7270 CERTIFICATION STATEMENT I certify that I have personally inspectec 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 _ Conditionally Passes _ Needs Further Evalu io By the Local Approving Authority Fails Inspector's Signature: Date:4/1/00 The System Inspector shall su mit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of completing this inspection.If t e 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 inspection is based on criteria defiled in Title V code 310 CMR 15.303.My findings are of how the system is performing at the time of inspection.My inspection does not imply any warranty or guarantee of the longevity of the septic system and any of its component's useful life." THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING THE SYSTEM EVERY TWO YEARS FOR PROPER MAINTENANCE. revised 9/2/98 Page 1 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 89 CHERRY TREE RD. COTUIT, MA 02635 M018 P012 Name of Owner DAVID MORSE Date of Inspection: 3/31/00 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: X 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. 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. nla 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:)r 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. nla 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 _otstruction is removed _distribution box is levelled or replaced n& 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 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 89 CHERRY TREE RD. COTUIT, MA 02635 M018 P012 Name of Owner DAVID MORSE Date of Inspection: 3/31/00 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 nta(approximation not valid). 3) OTHER n/a revised 9/2/98 Page 3 of 11 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 89 CHERRY TREE RD. COTUIT, MA 02635 M018 P012 Name of Owner DAVID MORSE Date of Inspection: 3/31100 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 Q. _ 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 compounds, 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 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 9/2198 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 89 CHERRY TREE RD. COTUIT, MA 02635 M018 P012 Name of Owner: DAVID MORSE Date of Inspection: 3/31100 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)] 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 Property Address: 89 CHERRY TREE RD. COTUIT, MA 02635 M018 P012 Name of Owner DAVID MORSE Date of Inspection: 3/31/00 FLOW CONDITIONS RESIDENTIAL: Design flow: 110 g.p.d./bedroom Number of bedrooms(design): 3 Number of bedrooms(actual): Total DESIGN flow: 330 gpd Number of current residents:2 Garbage grinder(yes or no):NO Laundry(separate system)(yes or no): NO If yes,separate inspection required Laundry system inspected(yes or no): NO Seasonal use(yes or no): NO Water meter readings,if available(last two year's usage): n/a gpd Sump Pump(yes or no): NO Last date of occupancy: n/a COM M ERCIAL/INDUSTRIAL Type of establishment: n/a Design flow: n/a gpd(Based on 15.203) Basis of design flow:n/a Grease trap present:(yes or no): NO Industrial Waste Holding Tank present:(yes or no): NO Non-sanitary waste discharged to the Title 5 system:(yes or no):NO Water meter readings.if available: n/a Last date of occupancy:n/a OTHER: (Describe) n/a GENERAL INFORMATION PUMPING RECORDS and source of information: AUGUST 99 BY BORTOLOTTI System pumped as part of inspection:(yes or no):NO If yes,volume pumped n/a gallons Reason for pumping:n/a TYPE OF SYSTEM X Septic tank/distribution box/soil absorption system _ Single cesspool _ Overflow cesspool _ Privy _ Shared system(yes or no)(if yes.attach previous inspection records,if any) _ I/A Technology etc.Attach copy of up to date operation and maintenance contract _ Tight Tank Copy of DEP Approval Other:n/a APPROXIMATE AGE of all components,date installed(if known)and source of information: 1986 Sewage odors detected when arriving at the site:(yes or no). NO revised 9/2/98 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 89 CHERRY TREE RD. COTUIT, MA 02635 M018 P012 Name of Owner DAVID MORSE Date of Inspection: 3/31100 BUILDING SEWER:X (Locate on site plan) Depth below grade: 12" Material of construction: _ cast iron X 40 Pvc _ other(explain) Distance from private water supply well or suction line: n/a Diameter: 4" Comments: (condition of joints,venting,evidence of leakage,etc.) THE SYSTEM HAS TOWN WATER. SEPTIC TANK: X (locate on site plan) Depth below grade: 12" Material of construction: X concrete_ metal_ Fiberglass_ Polyethylene_ other explain: n/a If tank Is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NO Age: n/a Dimensions: 1000G L 8'6"H 6'7"W 4'10"" Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle: 33" Scum thickness: 0" 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: n/a 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.) THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. GREASE TRAP: _ (locate on site plan) Depth below grade: n/a Material of construction: _concrete_ metal_ Fiberglass _ Polyethylene_other Explain: n/a Dimensions:n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle n/a Date of last pumping: n/a Comments: (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.) nla revised 9/2198 Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 89 CHERRY TREE RD. COTUIT, MA 02635 M018 P012 Name of Owner DAVID MORSE Date of Inspection: 3/31/00 BUILDING SEWER:X (Locate on site plan) Depth below grade: 12" Material of construction: _ cast iron X 40 Pvc _ other(explain) Distance from private water supply well or suction line: n/a Diameter: 4" Comments: (condition of joints,venting,evidence of leakage,etc.) THE SYSTEM HAS TOWN WATER. SEPTIC TANK: X (locate on site plan) Depth below grade: 12" Material of construction: X concrete_ metal_ Fiberglass_ Polyethylene_ other explain: n/a If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NO Age: n/a Dimensions: 1000G L 8'6"H 6'7"W 4'10"" Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle: 33" Scum thickness: 0" 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: n/a 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.) THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. GREASE TRAP: _ (locate on site plan) Depth below grade: n/a Material of construction: _concrete_ metal_ Fiberglass _ Polyethylene_other Explain: n/a Dimensions:n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle n/a Date of last pumping: n/a Comments: (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.) n/a revised 9/2/98 Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 89 CHERRY TREE RD. COTUIT, MA 02635 M018 P012 Name of Owner DAVID MORSE Date of Inspection: 3/31/00 TIGHT OR HOLDING TANK: _ (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: n/a Material of construction: _concrete_ metal_Fiberglass _Polyethylene _other Explain: n/a Dimensions: n/a Capacity: n/a gallons Design flow: n/a gallons/day Alarm present: NO Alarm level:N/A Alarm in working order:NO Date of previous pumping: n/a Comments: (condition of inlet tee,condition of alarm and float switches,etc.) n/a DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet invert: n/a Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) n/a PUMP CHAMBER: _ (locate on site plan) Pumps in working order:(Yes or No): NO Alarms in working order(Yes or No): NO Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) n/a revised 9/2198 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 89 CHERRY TREE RD. COTUIT, MA 02635 M018 P012 Name of Owner DAVID MORSE Date of Inspection: 3/31/00 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: n/a Type: leaching pits,number:(1)1000 GALLON LEACH PIT leaching chambers,number: (n/a)n/a leaching galleries,number: (nla)n/a leaching trenches,number,length: (n/a)n/a leaching fields,number,dimensions: (n/a)n/a overflow cesspool,number: (n/a)n/a Alternative system: n/a Name of Technology: n/a 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,THE SYSTEM SHOWS NO SIGNS OF FAILURE.THE PIT HAD 2'OF WATER IN IT AT THE TIME OF THE INSPECTION. CESSPOOLS: _ (locate on site plan) Number and configuration: n/a Depth-top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer. n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater: n/a inflow(cesspool must be pumped as part of inspection)NO Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) n/a revised 9/2198 Page 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 89 CHERRY TREE RD. COTUIT, MA 02635 M018 P012 Name of Owner DAVID MORSE Date of Inspection: 3/31100 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) o revised 9/2/98 Page 10 of 11 . 0 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 89 CHERRY TREE RD. COTUIT, MA 02635 M018 P012 Name of Owner DAVID M'ORSE Date of Inspection: 3/31/00 NRCS Report name: n/a Soil Type: n/a Typical depth to groundwater: n/a USGS Date website visited: n/a Observation Wells checked: NO Groundwater depth: Shallow_ Moderate_ Deep_ SITE EXAM _ Slope _ Surface water _ Check Cellar _ Shallow wells Estimated Depth to Groundwater 10 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 conditiions Checked with local Board of health _ Checked FEMA Maps Checked pumping records Checked local excavators,installers X Used USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) UGSS MAPS AND CHARTS-10+ FEET revised 9098 Page 11 of 11 f 02- Alp ©%8-O/1� L O CATION SEWAGE PERMIT NO. VILLAGE INSTA LLER'S NAME i ADDRESS S.UILDER OR OWNER 7- DATE PERMIT ISSUED DATE COMPLIANCE ISSUED ID Gj� D� o . /L Grc 6� 61.E_ ASSESSORS MAP N0: 2 PARCEL NO.: /Z No ... v Fss...... THE COMMONWEALTH OF MASSACHUSETTS C�UGKc`Nti Ncc�� BOAR® OF HEALTH _._.......... 0..�`///........OF......���� .�r Cyty� 7-�e— _� s I ................ l�"— .............. / Appliratioo for %gvwial lgorkg Tooitrurtiort pamit Application is hereby made for a Permit to Construct (W-1 or Repair ( ) an Individual Sewage Disposal System at ... .. Z .--�Z�......-- �"o ` - --...--- ................ Location-Address or Lot No. .................... Owner Addres W ' ..........� ................. ............. = `f— ............................ Installer Address d Type of Building q Size Lot....1411.4142S feet U 0-4 Dwelling—No. of Bedrooms..................`....... ................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers ( ) — Cafeteria ( ) a Other fixtures --------------------------------- - W Design Flow...............?....................gallons per person per day. Total daily flow.......... . ®.........................gallons. WSeptic Tank—Liquid"capacity.Ygaagallons Length__- * Width__4_'G.'.. Diameter---------------- Depth...-5 fig.`, x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area.................... ft. Seepage Pit No..........L-_____--- Diameter.......la-�..... Depth below inlet....._G.�..._._.. Total leaching area.. _ 6. ..sq. ft. Z Other Distribution box ( ) Dosing tank ( ) '" Percolation Test Results Performed by----- W!�!Z!�......�s q%Y---... Date__... ,Y.1!�L.---9B� Test Pit No. 1..4..Z..Jninutes per inch Depth of Test Pit..... _..... Depth to ground water.......-®'........_.. Test Pit No. 2....15�. ._minutes per inch Depth of Test Pit.... ...... Depth to ground water-----_............... P4 ................ O Description of Soil L y `�®eT� .. .._.Sv�3=SkiG� ��.. 3..�� co% -sue / '� V ----• •-- ••----•• -•----•---•---------••------------------------ ..........-•--.._......-----------•-•-•-•- W ••--.._..-••-------•--------•-------....-•----------•-------------------•---•-.......-•••-•----...----•-••----•---------........---•-------••--•------•---•-----••••--------....._...................... UNature of Repairs or Alterations—Answer when applicable-----------------------------------------------------------..................................... ---.................................••------•--••-••••....-•••-...••-----••-••--••-....-•--.......•-•-•-••••-•••--•-•----------•••--•-•-------•••••-••--•-•••••-••-----•••--••--....---••-•-----...... Agreement: The.undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of',== 5 of the`State Sanitary Code—The undersigned fur Iher agrees not to place the system in o eration until a Certificate of Compliance has en is ed by oard •-• ---•- .---------•-• ----•-•-•-•----•---- Application 'Approved By---•-•------....-- --- ••------ !n..... Date Application Disapproved for the following reasons---------------------------------------------------------------------------------------------------------------_ .........................................••----......................•............. .............. Date PermitNo......................................................... Issued........................................................ Date '. f, ` THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........._, _i,r/� /.........OF..........!`.... .... Appliration for Diiipnsal Works Tomitrnriiun jiumit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: w . -••-•------.... ................. --•--•-•-•------•----•--•---.---•---•-- --• -•--- ----------•---•----or, ---.-•-------------•---•. ...........__. ! Location-Address or Lot No. ................................•-----•--•- ...-------•-•---••-••......--•--••-•-•-•--•--•. ..........----.............._............. .. .................` ---------- Sc. Owner Address � .................. ............/-•.../ ...../.......-•-•--............................................. Installer Address Type of Building Size Lot___ Gd4 a__-_-._Sq. feet Dwelling—No. of Bedrooms.............................._...._____..__Expansion Attic ( ) Garbage Grinder (PL4 ) Other—T e of Building No. of persons............................ Showers — Cafeteria � Other fixtures ------------------------• -----------------------••---••••---•-•--------•-•-------------------------••-•••-----------------------------.........---- W Design Flow...............'._....__._____._._._.gallons per person per day. Total daily flow..__..___3.3a._._...... ........_.._gallons. WSeptic Tank—Liquid capacity!oo5;e.gallons Length._�..G.:___. Width_..G_."__ Diameter________________ Depth...~'. ".- x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area___...........__.sq. ft. Seepage Pit No.........l_._____-- Diameter------ ?./..... Depth below inlet_._..'_........... Total leaching area.....�.e_ .....sq. ft. Z Other Distribution box ( ) Dosing tank ( ) 0-4 Percolation Test Results Performed b _.__L r.s.c�i ! ----.-f:-:_--1 7 G _ -•--.- Date..._`T` 5C� y �`-------- -------- Test Pit No. 1._�... .....minutes per inch Depth of Test Pit.... Depth to ground water.._....'°"............. li, Test Pit No. 2....'_.-`•._minutes per inch Depth of Test Pit._._1`........ Depth to ground water___________________ a ------•----•------•...•----•--•-----••--•--------------------------•-------...............--•-...---...-----------•.........---•-•-•----------•--...------•-- O Description of Soil---- - �' l�'r�c. fG,4 5 c�c:: s . 2 4--{3 6 l `'"�r s :_._.. l' ---•- ------ --- -- W -------•-•---------•--•••--------------------•-•--•-•------•---------•------•------------•••-----------•-••--••---------------......--•-------•----•-------•---••--------•------•-----•--......--•-•---- UNature of Repairs or Alterations—Answer when applicable...................................................:........................................... ----------------------------•-------------------------------........--••------------------•--•---...---•----------------------------------------------------------------------------•-••..........••---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITTIE 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 he board,of'.halfih:t Ygkl - - --`. ..f_............................ate 7 �. Application Approved By_... ........... ....--• --�--------- n Date Application Disapproved for the following reasons-------------------------------------------------------------------------------•-------------------------------- ------------ -------------------•---.....--.-----•------------------------------ --------- --------- ... -----------------•-----------------•----------------------------------------------------- Date PermitNo......................................................... Issued-----------•----------..._...............•----•---•-••. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .to/. :�......OF.......... -- E�' 5�. J^?? I......................... Trrtifiratr of Toutplianr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (ice) or Repaired ( ) In staller has been installed in accordance with the-provisions of.TITLE E 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No._ "'�.__. -!r?... .... dated_ �..��.. _.`� THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL -FUNC 10 SATISFACTORY. DATE.. Z�.. .. .. � 6Inspector - ............................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH /.......................OF.. i/� ,, No FEE._... ....... ~ nrk� ��an,��rn�inn rruti� Permission is hereby granted------. =,�-A ..14---------------------------------------------------------------------------------------------------------------- to Construct (Wf or- -1pair ). an In rvi al Sevctag pisposal System .„ atNo..........................................._.... ..........----•-----....... - ..-•.......... .......................... J Street I .-T" t as shown on the application for Disposal Works onstruction Perm t,•N.6r1:L:�:_V3-:w r Dated___4:���_� _ �.: ...... 1. .............................. a. c r. �i t 4J_1. �`•-6.....::.-. .- .._... _ lO �. G M, b� Board of Health DATE..K ----- ...-•-- ...... - FORM 1255 HOBBS & WARREN. INC., PUBLISHERS ' 2- SHEETS W � / I ° s&srW/ I ELF/. lap v/= M'� 3o.00 3� /4ss &rD hkwle•z 28 r /9 Z, �.v dr&-v 7Vp of /6� aoo Sep. �T, 4 o ,�' � P2opostz� Fau Nv. :. 3/.o 0 � 0 b T'_ - - GEC/ ell, LOCATION .B� STH%3GG �Co>vs7) SCALE . ./,r-:3a.� .... DATE PLAN REFERENCE . ..S !�!�!. . .�!�. . . .. OF o ED EA�i[/, J� LEY . . . . . . .. .. . . . . . . . . . . . . . . . . . . . . . . o. 26 i OO an I CERTIFY THAT THE SHOWN ON THIS PLAN IS LOCATED ON THE GROUND AS SHOWN HEREON; DATE . .. . ..... . . . . . CARC JD6�/C.0/ s-svC. Pe-7-177o•16-lz REGISTERED LAND SURVEYOR TOP OF FOUNDATION e CONCRETE COVER CONCRETE COVERS 2.4i •'0 4' CAST IRONT %� ° OR SCHEDULE 402 MAX 12"MAX. 4' SCHEDULE 40 PVC.(ONLY) P.V.C. PIPE PITCH I/4"PER.F PIPE - MIN. LEACH ° T PITCH 1/4"PER,FT PIT PRECAST -� LEACHING -INVERT Q ` o EL.. �`l.. INVERT INVERT ° . e•: PIT OR °•, SEPTIC TANK Zg,Z/ D15T. z7.94 W EQUIV. o INVERT EL.. . BOX EL.. >_ 1• � o; EL. zB,38•. �DoO. .. GAL. INVERT �� ww %: EL........ INVERT u�o `: ::�. 3/4"T011/2 WAS o � EL.?...70, LL w STONE L6'DIA. --+-� IDIA.:!q.D� _ PROR LE OF GROUND WATER TABLE SEWAGE DISPOSAL SYSTEM NO SCALE SOIL LOG WITNESSED BY : DATE .ruGy !S/Jf'�STI ME. .��'oo / .74r7e3 .B, BOARD OF HEALTH TEST HOLE I TEST HOLE 2 5ZWi97ZD 67• /G-G.G-'y ENGINEER ELEV. . woo�Le/a-w� •vooDfo,o•r� . z¢� S�9-so,t. •, S�g_So,L DESIGN DATA ' �z, L7,7o Get. 27.7v C�,q-rase sa+ro G,M�SE SAr�D 3e..i ¢ 62gy�o 36" NUMBER OF BEDROOMS 3 Art.U•7, 6-7, Z,,7o 48" TOTAL ESTIMATED FLOW . . 33o GALLONS/DAY BOTTOM LEACHING AREA SQ.FT. /PITIC. 0 D. Mom, Mom. 40"17- GoTLiT SIDE LEACHING AREA SO.FT, PIT147/ P.D .5/0-,o s/I D GARBAGE DISPOSAL .Nor/C. • (50 % AREA INCREASE) TOTAL LEACHING AREA .2-67 00• SQ.FT PERCOLATION RATE ���. ?�`!�^��. MIN/INCH LEACHING AREA PER PERCOLATION RATE .�'`30.. SQ.FT./r.,0p /✓o WATER ENCOUNTERED A17- Wi7V NUM aNC-f BER OF LEACHING PITS . . . . APPROVED . . . . . . BOARD OF HEALTH n'�!o• �T D� -S7'vn/� oAl /ALL S/D6,T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DATE . . . . . . . . . . AGENT OR INSPECTOR OF 9 OF o EDVt�fiU _ E..- N 2— R. ti � F,L�LLEY � � No. 26100 � . .C'�/�� •T72� • /10/�� `��°: AECIs, CoTLi T' 5 S PETITIONER 1-7�3/Civ T�vG I