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HomeMy WebLinkAbout0334 COTUIT BAY DRIVE - Health 334`Cotuit Bay Drive A-=-055-006 — -- Cotuit - -- _ a) 0 r.. ... . Commonwealth of Massachusetts . _ F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 334 Cotuit Bay Dr. Property Address: > Graham &Joanne Harrison Owner Owner's Name information is required for every Cotuit Ma 02635 4/12/14 page. City/Town State :Zip Code Date oflnspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end.of the form. Important:When A filling out forms . General Information . on-the computer, I use only the tab f. . key to move your 1. Inspector: _.. cursor-do not.. Ricky L. Wright. Use the return.key. Name of Inspector _.. B&B Excavation Company Name 14 Teaberry Lane Company Address Sandwich Ma.::. 02644 .: City/Town State Zip Code (508)477-0653 S14595 Telephone Number License Number B. Certification _ . I certify that I have personally inspected the sewage disposal system at this address andthat the information reported below is true, accurate and complete as of the time of the:inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15000). The system: ® Passes. Conditionally Passes ❑ ,Fails Needs Further Evaluation by the Local Approving Authority 4/12/14 .Inspector's Signature - Date P 9 The system inspector shall submit:a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a desigh.flow of 10,00.0 gpd or greater,.the inspector and the system owner shalt submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner ...and copies sent to.the buyer, if:applicable, and the approving authority.. ***This report only:describes conditions at the time.of inspection and under the conditions of use at.that time..This inspection does.not address how.the system.will perform in the future under thesame or different:conditions of use. : �o d l5ins•3113:;: :::; Title 5 Official InsjtForm:Subsu rface Sewage: sposal System:•.Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments nM 334 Cotuit Bay Dr. Property Address Graham &Joanne Harrison Owner Owner's Name information is required for every Cotuit Ma 02635 4/12/14 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 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. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form _ - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 334 Cotuit Bay Dr. Property Address Graham &Joanne Harrison Owner Owner's Name information is required for every Cotuit Ma 02635 4/12/14 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): . ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ NO (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 334 Cotuit Bay Dr. Property Address Graham &Joanne Harrison Owner Owner's Name information is required for every Cotuit Ma 02635 4/12/14 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must I be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to 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 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 '/ day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 334 Cotuit Bay Dr. M Property Address Graham &Joanne Harrison Owner Owner's Name information is required for every Cotuit Ma 02635 4/12/14 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 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. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) 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. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate ' regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 1 Commonwealth of.Massachusetts _ Tit e 5 Official Inspection Form M Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 334 Cotuit BY D a r. Property Address:. Graham &:Joanne Harrison Owner Owner's Name • information ie required for every Cotuit Ma 02635 4/1.2/14' . page Cityrrown State Zip Code : Date oflnspection C. Checklist .. Check if the following.have been done: You must indicate":yes" or"no" as to each:of the following: Yes: No - .. 0 [A Pumping information was provided by the owner, occupant, or Board of Health Ej M Were.any of:the.system components.pumped out in the previous two weeks? M El Has the system received normal flows_in the previous two week period? Have large volumes of water been introduced to the system recently or as part of 0 ® this inspection? Were:as built-plans of the system obtained and examined?(If they.were not. ® available note as N/A) ® 0 Was the.facility or dwelling inspected for signs of sewage back up? 1Z 0 Was the site,inspected for signs of break out? ..® 0 Were all system components, excluding the SAS, located on site? . 0 0 Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum?' Was the facility owner(and occupants:if different from owner) provided with El . El 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: 0 0 Existing information. For example, a plan at the Board of Health. Determined in the field(if any.of the failure criteria related to Part C is at issue ® 0 :::approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential,Flow Conditions: 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) 440 t5ins•3)13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17: Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 334 Cotuit Bay Dr. Property Address Graham &Joanne Harrison Owner Owner's Name information is required for every Cotuit Ma 02635 4/12/14 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage n/a 9 ( Y 9 (gPd))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: May 2013 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease.trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 334 Cotuit Bay Dr. M Property Address Graham &Joanne Harrison Owner Owner's Name information is Cotuit Ma 02635 4/12/14 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® .Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no)(if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the l/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 334 Cotuit Bay Dr. G„M Property Address Graham &Joanne Harrison Owner Owner's Name information is required for every Cotuit Ma 02635 4/12/14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 4/4/84 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 7 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: >20feet Comments(on condition of joints, venting, evidence of leakage, etc.): At time of inspection building sewer appeared to be in good working order no sign of leakage. Septic Tank(locate on site plan): Depth below grade: 6 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gal. Sludge depth: no sludge t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 334 Cotuit Bay Dr. Property Address Graham &Joanne Harrison Owner Owner's Name information is required for every Cotuit Ma 02635 4/12/14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle no sludge Scum thickness no scum Distance from top of scum to top of outlet tee or baffle no scum Distance from bottom of scum to bottom of outlet tee or baffle no scum How were dimensions determined? scour stick Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): At time of inspection septic tank appeared to be in working order,Tees present no sign of back- up.Liquid level equal with outlet invert. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 334 Cotuit Bay Dr. Property Address Graham &Joanne Harrison Owner Owner's Name information is required for every Cotuit Ma 02635 4/12/14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 334 Cotuit Bay Dr. Property Address Graham &Joanne Harrison ' Owner Owner's Name information is required for every Cotuit Ma 02635 4/12/14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 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.): At time of inspection d-box appears to in working order no sign of deteration, or carryover.Recomend riser. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 334 Cotuit Bay Dr. Property Address Graham &Joanne Harrison Owner Owner's Name information is required for every Cotuit Ma 02635 4/12/14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: I, ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation, etc.): At time of inspection leaching appears to in working order no sign of hydraulic failure.Leaching was dry at time of inspection. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 r - Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 334 Cotuit Bay Dr. Property Address Graham &Joanne Harrison Owner Owner's Name information is required for every Cotuit Ma 02635 4/12/14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts _ . f Title 5 official Insp action Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 334 Cotuit Bay Dr: Property Address Graham &Joanne Harrison : Owner Owner's Name information is required for every COtult page. City/Town. ... Ma 02635. 4/12/.14 . .... _. _.. :..:State ZipCode Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System:.Provide a.view of the sewage disposal system, including ties to : at least:two permanent reference landmarks or benchmarks':Locate:all wells within 100 feet. Locate where public waster supply enters thebuilding. Check one of.the boxes below: ® hand-sketch in the area below El drawing attached separately D , : _. _.. 0 /A l 2. "3 D I Yai1' .. 134 = °z7 t5lns•3/13. Title S.Official Inspection Form:Subsur face rface Sewage Disposal System•Page 15 of 17 : f Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 334 Cotuit Bay Dr. Property Address Graham &Joanne Harrison Owner Owner's Name information is required for every Cotuit Ma 02635 4/12/14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells >132" Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 4/4/84 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers -(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: records at B.O.H. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts w Title 5 .Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 334 Cotuit Bay Dr. M Property Address Graham &Joanne Harrison Owner Owner's Name information is Cotuit Ma 02635 4/12/14 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 CdTc.,T 134y 7' . a � d n� ss - ao--� _S�` LOT .NO. �'' ADDRESS : �Av, T /.3W /�/le` OWNERS NAME ' Glet,�l�j� 11 rZQis e A SEWAGE PERMIT NO. NEW: P--- REPAIR: DATE ISSUED:5`9--t? DATE •INSTALLED: 7-3 -8 ,51 INSTALLERS NAME:_ A)yo1/`ga1 INSTALLATION? OF : WATER TABLE: FINAL INSPECTION BY: DRAWING OF INSTALLATIQN ON REV RSE SIDE : coTv/r 134X f t� �QP7 M to 7' TOWN OF BARNSTABLE LOCATION SEWAGE# VILLAGE ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY. (type) (size) NO.OF BEDROOMS OWNER PERMIT DATE: COMPLIANCE DATE: 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 1 .0-4 Fas.... .............. rt THE COMMONWEALTH OF MASSACHUSETTS 0 BOARD OF HEALTH(� !Si�OW. .................OF.....I ,o.`C'Y1STc` �` Appliratiun for Uhip utti lVark.5 Tonstnutiun Vrxmit Application is hereby made for a Permit to Construct (x) or Repair ( ) an Individual Sewage Disposal ystem at - 0.` O�;vim ._._... ..... La `s £_g��,.= 'p�art31 -�,z�.P9.z� ._. ---- • -• ------- cation-Address -..-or.Lot No. •• D ..........: __.-------•.......... .....• .- --• •----.•--• --................... _....._.. er Address W — Installer Address Type of Building d Size LotS... _.. fSFt U Dwelling—No. of Bedrooms....... T________________________________Expansion Attic ( ) Garbage Gri er/ (J) 04 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeter a' Other fixtures ...................... .. . W Design Flow............`JS___________-------------gallons per person per day. Total dai}y flow...._...4..............................gallons. WSeptic Tank—Liquid capacity l_�SS!.gallons Length....11........ Width:._.5;�_._....:Diameter................ Depth...4........ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.....z........... Diameter.......8....... Depth below inlet.....G.......... Total leaching area.8 `�: sq Cam'D Z Other Distribution box Dosing tank ( ) '"' Percolation Test Results Performed by .....Y-eANe` ................ Date. ........................ 0.4 Test Pit No. 1...�.......minutes per inch Depth of Test Pit..:_I 4.`........ Depth to ground 44 Test Pit No. 2................minutes per inch Depth of Test Pit.....1.4".61__... Depth to ground water......... n+ ----•----- -• v . 'O Description of :e-.... . .... ___._ _V� .._ -----------------•__------------------------ -•-----•••----•-•-•- ----�-•--------............ ...--------------•--•-........•---.._...........-----_.......------_---- x •---•-••------------------ ---•------- ---------•------------------------------------.....------•--•------•----------•-•------......--•----•------.....-----.._..-•--•----------------•--•-••••--•--•_.. V 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 TL I TL LZ 5 of the State Sanitary Code — The undersigned further agrees not to place the system in operation until a Certificate of Compliartce has been is ed by the board of health. Signed.......... ----- ........::- .............., ......_.... Application Approv •....................................................•---....._....._.._•--•.........-- f Appli ti Disapprove f o h f-Mowing reasons: =------------------••-. ' f ......... -------••••--------••----••--•------••-•-- ••-----------------•---------- ------ Permit No.......................................................... Issued.--- a. k w THE COMMONWEALTH OF MASSACHUSETTS 5 BOARD OF HEALTHhl- 1 Tow r�..................OF....��Olr nZ ,k Q_ ..............-..._._.. "Y .�ppliratiun fur Di,ipaaal Works Tonstrudion Prrutit Application is hereby made for a Permit to Construct O or Repair ( ) an Individual Sewage Disposal System at: .. �?ta` . Qr��E .. ..a- s $'1 �• ara�,.. p1� G3k..2�2 P�,2r ... -- ••-- ------ hh� /• cation Address or Lot No. JCL ------ ............................................. ^. ........_......._................ ner IJ A W ' ddress ,.a �._.. :. ........................................... Installer Address Type of Building Size Lota... �`-r�- Sq. feet Dwelling—No. of Bedrooms....___4.....:..........................Expansion Attic ( ) Garbage Grinder�,(e) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria'-(' ) Q Other fixtures . W Design Flow........... ? ?.........................gallons per person per day. Total daily flow........`� ...____. ._....._.___gallons. W Septic TI fnk—Liquid capacityVt§�.gallons Length._.. �_ ....... Width---------------- Diameter................ Depth... x Disposal Trench—No..................... Width..__...._.. ... Total Length-,........ Total leaching area.................... ft. 3 Seepage Pit No.....2............. Diameter......�.._..... Depth below inlet..._..... ....... Total leaching area.8 i G.sq;-ft. G!D Z Other Distribution box (\/) Dosing tank ( ) Percolation Test Results Performed by 17 00,r ms._�`�eA e". l'•'n9 :••.•_ - Date. A I k I a -...-il ..;......................... Test Pit No. .......minutes per inch Depth of Test Pit....t`..::�...... Depth to ground water..n9n'P1_.__.._. 44 Test Pit No. 2................minutes per inch Depth of Test Pit.... !qr---- Depth to ground water.......!`7n :_°`_�n���� 0 Description of Soil.... - ...oc .c ir.� l� a•�..':`..'...`.. ............•-•----•----------•-- U ----------------------------•-•--------•----•-----------••---------------------- ........ ................------ •-------------------- .------ ..._._... --.------.. -.•-......------- W VNature 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 TIT?.' 5 of the State Sanitary Code— The undersigned-further agrees not to place the systemrin operation until a Certificate of Compliapce has been is ued by the board of health. .W . y Signed !` .r- _------------ ^. _ Application Approv �Date Applicati D> approv f o t�h following reasons -----•-------•-------••-•-•---•--------•-----••---•---•---••-------•-••..............................•- ...:. ................................. Date PermitNo......................................................... Issued..................•--- ............................. Date f f /'THE COMMONWEALTH OF MASSACHUSETTS# BOARD OF HEALTH x �, LL (Irrfifiratr of flout hanrr T S 0 CERTIFY, That the Individual Se •age Dispose System constructed ( �,orRepaired ( ) by.. -•- ....--•- -- ...... !' •-••-•--•.............................•-- '" Installer " at..... --- . .......�-•%�- t.. ... =.. ..... _�__.... ....................................•-•.......------.... has been installed in accorrdanr with ie provisions of Tarr � j �ie State Sanitary Code as described in the application for Disposal-Works Construction Permit ..................... dated':-: .............................. THE ISS AN E OF THIS CERTIFICATE SHALL.NOT BE CONST. D AS A GUAR TEE THAT THE SYSTEM WILL- CTION SATISFACTORY. DATE..../. °.:........: ...................................................... Inspector... --..._...... •--••- THE COMMONWEALTH.OF MASSACHUSETTS BOARD OF HEALTH No.f... ............... .................................OF...................... ...... , ........•--•• ................ F> ................ iupou k11 (10 utrwi n Frrutit Permission is hereby granted.....'.._ ....... --• -- •----- -------------•----- ............... to Construct r Vair I wlr] Se a Dis S stem P Yat N ........ . ....... f.. -,��=. -----••-- ............... •--•----•---......_...-------•-- ............................... Street as shown on the application for Disposal V4' s Construction Pe o..................... Dated........................................................... Boardof lealth................. --------------------_---.------------.... _ DATE----------------------- •- ....---............... v !f 1 S y v t _ SECTION — SEWAGE ^-SEPTIC TANK - - "D"BOX - - LEACH P IT , _~ • ~ TOP OF FDN •' \ \31 , I3� .. • ' R 3 (MSL)o WA HE}D STOONE IN- OUT- IN- 7 2'8•{© e-�58 SEPTIC r' TANK" ELEV. ELEV. ELEV. ELEV Z6.6 2(Z.5Z 22.0 _ r° - `4\ �- \\ �-�y+ 8� J� ELEV. ELEV. ELEV. -I' 1' �\ ! \ \ 4a�sat C>_reAL x % OF x."-1>h•• ti 311 01F /. , �\ Zg, 13 1 S \ ' WASHED STONE TEST HOLE LOG ti3 ° 3 . Tr1on�,s5 G. pAu` t.nuE1Z.,AY 3.0•:.► . " TEST BY Ic>:t_�..cyYF E..y, - -fEST DATE WITNESS DESIGN 4'-BEDROOM HOUSE Lf �� ~ �0 9 n T.H. * 1 T.:H.' * 2 � \K / dp� \ ELEV. 6> ELEV. NO DISPOSER DISPOSER 6 + I t�vM Su Sots v u,'75�ub,�o%L_ PERC RATE Z MIN/IN. \ g� /° 4 r Z4" '�2.Z z-4" 3Z•4 FLOW RATE 440 (GALJDAY) O SEPTIC TANK 44o x. (I:S1= O A�'a' Gop,�S cv {T 9Ana 1'� - O.0 ,Ti 'L• 1 t o .- ,e• w, R`EO'D SEPTIC TANK SIZE 1 00 t� ' t y - ' � z �� � 0 co aes c .T Sa..k Z� c, LEACH FACILITY - �? Q ,� -f•+ 3�� ; 1 / 1 `,k SIDE WALL £3 1Y�} - �00.5 (2-S) z 0 GID. BOTTOM 82 1.0 ) c 50.3 G/D. jog L5 1✓IED.s ca sc s�+.+r� TOTAL �,So.8 'S _ ��O f.•3 GJ{7 X Co02.�o G/L7 LOT S'7 a' Wo 1 �11 14�4" USE: LEACHING P 1T5 :' \ 1 , 144 Zz-z zZ•4 —�' EFF. DVPTW X S' EFF• 01AP�E"TeF- N� WATER ENCOUNTERED � -"r,N �, by 1?.Fot:rr�a•r,1K.,p..e., t •� .Z�b , ��_ - , .: ;,�''',. NOTES: (UNLESS OTHERWISE NOTED) CIO-an 28.E O .. 1. DATUM(MSL);TAKEN FROM...CoZvIT_-__-,---___•QUADRANGLE MAP �� � ` S �y )1�1 ( s 2.MUNICIPAL WATER....__...._•.__--------____...........AVAILABLE �►. G *`t 3.PIPE PITCH: 4:"PER FOOT O }1R1IE H. eJ� . R 4.DESIGN LOADING FOR ALL PRE-CAST UNITS:AASHO_ I -44, OJAIA •-+ { 4 +' 5.MIN.GROUND.COVER OVER ALL SEWAGE'FACILITIES:(1)FT. 23 cj C'ilVll —DISTANCE AS CERTIFIED ppy� 6. PIPE JOINTS SHALL BE MADE WATER TIGHT 1 �E • 7R O @ 4A E 0H x elenn rne.e�. No,307 �H. /�w' J.CONSTRUCTION DETAILS TO BE ACCORDANCE WITH COMM.OF MASS. -}o Ih@ � S C SITE PLAN jL'' STATE ENVIRONMENTAL CODE TITLE 5 21 $4n� �EG�i, ��� �GYi �`� SSG t `� cles.q o AIR E s L CUS:LDTS gl i57 A C1 TUC '�A.`i' _ b O}p LA' to �G{YTl.1 'sacs --- ---••4 �26�4f! ; - Snhd REG.PROFESSI AL ENGINEER: REF' • _�`- IC'- 7+ �' + ! 7w° f10 Wa�tQ.1 Encovn�er � �� il cape, �� �iF ��Q �j�y PREPARED FOR �A L.,����J U( �s�f't" K a ,� 'CIVIL -ENGINEERS ' - FvtZ G/-1/M)w 60-4 MV ' f LAND SURVEYORS :�TZO" IA St BOARD OF HEALTH AEG.LAND S RVEYOR EXISTING ----_• - SCALE�Lt 1��tA (PROPOSED)-0-0-0-0— APPROVED DATE - *• MA � :�•� - r•A1� 5ya *ti=•�^` .r y 1'eV � , CONTOURS TE p40 � '.}