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HomeMy WebLinkAbout0028 CROCKERS NECK ROAD - Health 28 Crockers�Neck Road Cotuit P A = 020 093 !I I� I �,r �O = ------------ gO t � � z L t I I# 15 } j .r PERM S � Oft 1;2ft. 24ft 36ft floor g planner i i f t =g hY t S E s - N ._c -------------- IN r 3 Oft 1.2ft 24ft 36ft _.___ ....... .._. __ floorOplanner v C ZZ E t f f f Oft.. 12#t 24ft 3,6ft floor planner f (`Vry14A\1 £ V a J I ;vim j o I v 51011 80 L � s t 0: . r 1 t � I f Off 12ft. 24ft 3.6t floor gy planner 4 i i f �V F i ^ F � � 4 - .............. --- Oft, 12ft 24ft 36ft floor fy planner k COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 28 Crocker Neck Road cotuit, AM RECEIVED Owner's Name: Marian Anderson Owner's Address: 25 Constitution Drive APR 17 2002 Southboro, MA 01772 Date of Inspection: March 29, 2002 TOWN OF BARNSTABLE HEALTH DEPT. Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Mailing Address: P.O. Box 49 Map: 020 Osterville,MA 02655-0049 Parcel: 093 Telephone Number: (508) 862-9400 CERTIFICATION STATEMENT 1 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 the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ✓ Passes Conditionally Passes N Further Evaluation by the Local Approving Authority Fa Is Inspector's Signature: Date: April 1, 2002 The system inspector shall subm a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 28 Crocker Neck Road Cotuit, MA Owner: Marian Anderson Date of Inspection: March 29, 2002 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. Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: 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 ND explain: l The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 28 Crocker Neck Road Cotuit, MA Owner: Marian Anderson Date of Inspection: March 29, 2002 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 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 28 Crocker Neck Road Cotuit, AM Owner: Marian Anderson Date of Inspection: March 29, 2002 D. System Failure Criteria applicable to all systems: You must indicate either`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 '/z day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. ✓ Any portion of the 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either`yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area- IWPA)'or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 28 Crocker Neck Road Cotuit, AM Owner: Marian Anderson Date of Inspection: March 29, 2002 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No ✓ Pumping information was provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection ? ✓ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up? ✓ Was the site inspected for signs of break out? ✓ _ Were all system components,excluding the SAS, located on site? ✓ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum ? ✓ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No ✓ _ Existing information. For example,a plan at the Board of Health. ✓ _ Determined in the field(if any of the failure criteria related to Part_ C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)]. 5 i Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 28 Crocker Neck Road Cotuit, MA Owner: Marian Anderson Date of Inspection: March 29, 2002 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):. 5 Number of bedrooms(actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 Number of current residents: 0 Does residence have a garbage grinder(yes or no): No Is laundry owa separate sewage 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 2 years usage(gpd)): 2001- 76,060 gals.; 2000-4,000 gals. Sump Pump(yes or no): No Last date of occupancy: Weekend use COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system (yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Pumped on Apr. 30199-per treatment plant Was system pumped as part of the inspection (yes or no): 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) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Original system- 1984; new pit added in 1996 Were sewage odors detected when arriving at the site(yes or no): No 6 I Page 7 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 28 Crocker Neck Road Cotuit, MA Owner: Marian Anderson Date of Inspection: March 29, 2002 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 16" Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000 gal. Sludge depth: 1" - Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 0" Distance from top of scum to top of outlet tee or baffle: 10" Distance from bottom of scum to bottom of outlet tee or baffle: 14" How were dimensions determined: Measuring 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.): Tees were present. The liquid level was even with the outlet invert. There were no signs ofleakage. Scumisludge were minimal. GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 28 Crocker Neck Road Cotuit, MA Owner: Marian Anderson Date of Inspection: March 29, 2002 TIGHT or HOLDING TANK: None (tank must.be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete metal _fiberglass _polyethylene _other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working (Y or no)order es : Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even 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.): The D-box was level. There were no signs of solids. PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 r. Page 9 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 28 Crocker Neck Road Cotuit, MA Owner: Marian Anderson Date of Inspection: March 29, 2002 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 2-6'x 6'(old pit w/2'stone and new pit with 4'stone-per as built card) leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: Innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): The new pit was dry. The scum line was Y up from the bottom. There were no signs of failure. The bottom to grade was approximately 9. The cover was approximately 28"below grade. The older pit was not dug up. CESSPOOLS: None (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 or no): Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: None (locate on site plan) Materials of construction: ' Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 9 Page 10 of 11 " OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 28 Crocker Neck Road Cotuit, AM Owner: Marian Anderson Date of Inspection: March 29, 2002 Map: 020 Parcel: 093 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. fat - 1 C) A3- Q3. SO, to n c.w D L, 10 Page 11 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART,C - SYSTEM INFORMATION (continued) Property Address: 28 Crocker Neck Road Coto, AM Owner: Marian Anderson Date of Inspection: March 29, 2002 SITE EXAM Slope Surface water Check cellar ' Shallow wells Estimated depth to ground water feet Please indicate (check)all methods used to determine the high ground water elevation: Obtained from system design plans on record- If checked, date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contours maps Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: The bottom of the leach pit to grade was approximately 9. Using the Barnstable topographic map and the Cape Cod Commission water contours map, the maps were showing approximately 38'+/-to ground water at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report. 11 o� I'TOWN OF BARNSTABLE LOtAnON �o CrOC�e/ /1eck SEWAGE # VILLAGE CQIKY� ASSESSOR'S MAP & LOT Q36 LO93 INSTALLER'S NAME& PHONE NO. SEPTIC TANK CAPACITY 10up LEACHING FACILITY: (type X GJ (size) yd"� NO. OF BEDROOMS BUILDER OR OWNER ✓V1A6)4/1 ✓ t,( C/S0/\ 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 leac ng facility) Feet Furnished by t )U✓I GArAAt- ICI Aa- 33 f3a- a� A3- 4444 41 Q3 new P.r a 3 oL P1 r f- J TOWN OF BARNST^ABLE s L ATIONS l s�o t\P l� �1� -1 SEWAGE #, ��'""' VELLAGE ac) 4 21 ASSESSOR'S MAP &LOT n � INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPAC= 4 LEACHING FACELITY: (type) �fle,) U Ir NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIAN DATE: Separation Distance Between the:_ Maximum Adjusted Groundwater Table and 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 o leac ' f cility) Feet ^�. Furnished by ���/1 rl / / Y1 h No.....7Y—_ - F� .3O_.00.... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABLE Appliration for Diripit ial Work.5 C omitrnrtinn Famit Application is hereby made for a Permit to Construct ( ) or Repair ( man Individual Sewage Disposal System at: �S -C �OG��f�2CGC R� ��fi r-............. .. •-------------•.....----•-----•........ ---------- -------- DLocation-Address I !l or Lot No. .............E_�.Gl✓L---..........._._ •---•-• •-- �---- '------•---------------------------------- Owner 5 USte fv,`Il eAddress ` 02$ -oZ�-1 v3 Installer Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms-_---•--------------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type 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-----_--_-_gallons Length________________ Width---------------- Diameter............... Depth................ x Disposal Trench—No. .................... Width_---------------... Total Length-------------------- Total leaching area....................sq. ft. 3 Seepage Pit No............._-_--- Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ,) Dosing tank ( ) Percolation Test Results Performed by-------------------------------------------------------------------------- Date........................................ Test Pit No. I----------------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.....-.................. 1:4 -----•------- ---------------•--......----•--•--•---.•.. (•---••--•---•----•---•---------•-----••-•---•-------•---•........................................ 0 Description of Soil..................................................................... ------------------------------ ---------........................................................... x U --••---•-•-•-•--•----------•-------•----••-••-••-•-••--•-•-•------•----•--••---•---•----------•------••......... ..........•------•••----••-----•-------••-•---•----•---•-•-----...--•---•----••-•-•-••. W ---------------------------------------------------------------------------------------------------------------------------------------------------------••.......--------•---------...•-------•---•-•-- V Nature of Repairs or Alterations—Answer when applicable_-1,.--,a.....G_ca, _be-------- :T)-�....... .........__. --------••----------------- ---•---------------------------------------------------------------•-------•-•--.......----------•-------•-•--•-•-••----- ............................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed -........ ��� ..... _. .... ...--......7--- (� Date Application.Approved By ---------- \. .... ---- ---------------------- ---------------------------------------------- -- - --- Date Application Disapproved for the following reason.r- -----------------------------------------------------------------------------------....._......--------------------------------- ......_............_....-._............._....._......................_.........................................._............._.... ....--.. ........................................ Date Permit No- --------------C7 `-....... Issued ------------� ��-"�� ------------- Date ——————————— — — — — i No.... 2r-_ d Fs$...30.'oU_-... l THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE ApplirFatilaia for Di-nVaiiaal lVark.6 C owitrnrtiun Frrmit Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal System at: 02 8••-C wc.�e rRoR --------------------------------------------------------••--•.._..--•- - ------ •. ....................... fu fi Location-Address I t I I or Lot No. ....e-...... _... Qc�• e Owner S ILe e Address Installer Address UType of Building Size Lot............................Sq. feet .� Dwelling—No. of Bedrooms______________________________ -_;__Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of ersons____________________________ Showers — a YP g ---------------------------- P (----)-------Cafeteria ( ) Otherfixtures ------------------------------------------------•-•------------------------------------ -------------•-_----- Design Flow gallons per person per day. Total daily flow___________________________________________gallons. WSeptic Tarim.—Liquid capacity__-__-____gallons Length________________ Width---------------- Diameter---------------- Depth............... Disposal Trench—No_ ____________________ Width.................... Total Length-------------------- Total leaching area....................sq. ft. y Seepage Pit No-___-____----____w Diameter____________________ Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I________________minutes per inch Depth of Test Pit_--_.._..___________ Depth to ground water------------------------ fZ4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to .ground«water........................ O •---------------------------------------------------•------•------------------------._......._---•--......................................................... Descriptionof Soil........................................................................................................................................................................ W ------------------ ------- --------------------------------------------------------------------------------------------------------------------------------_:-----------------------••••----_-•-•-- V Nature of Repairs or Alterations—Answer when applicable - , ___ .��-_._.G r __P----_-_-- - 1-1 e-_---"IZ7 -a. Agreement: ` - ... The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. = , .......... .......... Signed ......... �. ---� ._ . .-s-�,-,��-- --�� Application,Approved B 1 J ?--- -.. .... _ _ _.................................... ....-.. ....--.....- .............- Date Application Disapproved for the following reasons- -------------------- ---------------------------------------------------------------------------------------------------------- --..--.-------------------------------------------------------_.-------.--.----...---------------------------------------------------------------------------------..-------_----------- --------------.Dare---------------- Permit No. .---------- - Issued - - - .............. Dace THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE &rtifira#e of CZumlatia nre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( tom) by ..... L f-.w 5--- at .. �-8.-_C <vC-vC. � A ec `-------Via----------- -0-.. :u_�..fi---------------------------------------------------------------------------- has been installed in accordance with the provisions of TITLE Scoff The State Environmental Code as described in the application for Disposal Works Construction Permit No. --.-----KJ_;�,..----.--- dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE ...--- ---- Inspector .s THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE No...... FEE3a- !; V.. Bispao l Works Tuntrudion '"rrmit Permission is hereby granted-------LING- t Lew ' ----------------------------------------------------------------•-----.........-- to Construct ( ) or Repair (Lan Individual Sewa e Disposal System atNo..... c>c K•...-•1-----........e-c-K•------ -b ` t----r--------------------------------------------------------------- Street CC��-- pp as shown on the application for Disposal Works Construction Permit No._??_- ---Dated___ _-_.�.�--_� .... 6Bo d of Health DATE...................... .o% ...................... V FORM 36508 HOBBS&WARREN.INC..PUBLISHERS ►��� a PAR p� r OMMONWEALT OF MASSACHUSETTS .: r, EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 TRUDY CORE Secretary ARGEO PAUL CELLU.CCi DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART A CERTIFICATION n Property Address: g 2.0 1CL X-Ni�C_f.O( Name of Owner bCAA) t 14i"R, C �-/177,4 ©2�0 3 S Address of Owner: 541t4C Date of Inspection: y-30_ 04 3 Name of Inspector:(Please Print) 1 am a DEP ,pproved system rns or pursuant to Section 15.340 of Ttde 5(310 CMR 15.000) Company Name: 1R> �- MaTing.Address: �— S 2/LUG' E, MIA O.-L& Telephone Number: , iz CERTIFICATION STATEMENT r* 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 2 maintenance of on-site sewa a disposal systems. The system: G�passes v Conditionally Passes k' ..� _ Needs Further. valuation y the Local Approving Authority Fail Inspector's Signature. Date:5? 4� The System Inspector sha;l submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty 130.)days of tW' 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 ownelr shall submit the report to 'he appropriate regional office of the Department of-Environmental Protection. The original should be sent tom system owner and copies sent to the buyer, if applicable, and the approving authority. i' NOTES AND COMMENTS 'R . r t A N ►iEdtt� r � 1 t 5 revised 9/2/98 Pagel of11 Printed on Recycled Paper �x r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A j y� Q� CERTIFICATION (continued) Property Address-1? T /Xn0&ee ` /ek A14 'Z_7? ' r Owner: [J�0$N !'Afi�l C/ 60 e Date of Inspection: U INSPECTION SUMMARY: Check A, .B, C, or D: a 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: 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 ye , no, or not determined(Y, N, or ND). Describe basis of determination in all instances. If "not determined",explain why not. The septic tank is metal, unless the owner-or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the{an k s installed within twenty (20)years prior to the d ite.of the inspection;or `� the septic tank, whether or not metal, is c ack d,,structurally unsound, shows substantial infiltration or exfiltration;-or tank failure is imminent. The system will ass nsp cti`n i the existing septic tank is replaced with a complying septic tank,as approved by the Board of Healt Sewage backup or breakout or I gh atic wat level observed in the distribution box is due to broken or obstructed pipe(i) or due to a broken, settled or un ven dist ibution box. The system will pass inspection if(with approval of the Board of Health). broken pipe(s) are rep, ced obstruction is removed distribution box is levelled or replaced The system I equired pumping more than four times a yeardue to broken or obstructed pipe(s). The System will V.. inspection if with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed r! i._ revised 9/2/98 Page 2ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address. &n Cxo&�-I°e 161e@/C 4 dp&tl. 44 ©o2(a..3S" /� 'i Owner: Qf AN 'L M7'1e1L11� Date of Inspection: i1 3d 9� C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Condition-- exist which require further evaluation by the Board of Health in order to deter !ne if the system is failing to protect the public health,-safety a the environment. SYSTEM WILL PASS UNL S BOARD OF HEALTH DETERMINES IN ACCORDA E WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A NER WHICH.WILL.PRQTECT THE PUBLIC TH.AND SAFETY AND THE ENVIRONMENT_. Cesspool or privy is 'thin 50 feet of surface water Cesspool or privy is wi in 50 feet of a bordering vegetate etland or a salt marsh. i 2) S STEM WILL FAIL UNLESS THE BOARD F HEA TH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS i NCTIONING IN A MANNER THAT P TECTS TH PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic ank and soil absorpt n system (SAS)and the SAS is within 100 feet of a surface water supply or, tributary to a surface 'ter supply. The system has a/seti.c tank and soil absorption ystem and the SAS is within a Zone I of a public water supply well. The system has ac tank and soil absorption s tem and the SAS is within 50 feet of a private water supply well.. The system has�a septc tank and soil absorption sys em and the SAS is less than 100 feet but 50 feet or more from A. private water}upply well, unless a well water analysi for coliform bacteria and volatile organic compounds indicates that the ,- well is free fom pollution from that facility and the pre ence of ammonia nitrogen and nitrate nitrogen is equal to or less ; than 5 pp .. Method used to determine distance (approximation not valid). *` 3) C THER `, Y/ i revised 9;2;98 Page 3of11 r. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (corrorxwed) Property Anddress:? U�G�f2 � � /C._ � d, 61-6 T', 1q,4. 0,)6?)- Owner: 'J- Date of Inspection: q-30- 9f D. SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: have determined that one qr more of the following failure conditions exist as des ed in 310 CMR 15.303. .The basis for this - determination is identified below. The Board of Health should be contacted to ermine what will be necessary to correct the failure. Yes Backup of eewage imoieciliYy�or-sntem component•duego overloaded ormiegged`SASar cesspool. s- Discharge or ponding of etfluei t to a surface of the gr and or surface waters due to an overloaded or clogged SAS or . c spool. Static 'quid level in the dist ibu ion x bove o let invert due to an overloaded or clogged SAS or cesspool. Licuid dept in cessp s le s han 6" bel invert or available volume is less than 1/2 day flow. Required pumpi more a 4 t es i the last year NOT due to clogged or obstructed pipe(s). Number of times p pe Ary portion of the Soil sorp ' n System, cesspool or privy is below the high groundwater elevation. Ary portion of a cesspool p 'vy is within 100 feet of a surface water supply or tributary to a surface water supply. Ary portion of a cess of or privy is ithin a Zone I of a public well. Ary portion of a c spool or privy is withi 50 feet of a private water supply well. Ary portion of cesspool or privy is less than 1 0 feet but greater than 50 feet from a private water supply well with no acceptable ter quality analysis. If the well has b en analyzed to be acceptable, attach copy of well water analysis for cwiform b teria, volatile organic-compounds, ammon nitrogen and nitrate nitrogen. E. LARGE SYSTEM FA S: You must indicate eith "Yes" or "No" to each of the following: The followi g criteria apply to large systems in addition to the criteria above: The sys am serves a facility with a design flow of 10,000 gpd or greater(Large Syst ) and the system is a significant threat to public;l health and safety and the environment because one or more of the following conditions ist: Yes o *r.. the system is within 400 feet of a surface drinking water supply the system=is-within 200 feet of-�iributarY tom surtaoe drir.kiwg water supply - --- - — — ed 2 ' n Area -IWPA or a ma one Il of., public ctio ) Interim Wellhead Protection PP the system is located in a nitrogen sen sitive area water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4oru SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:p L/�9 �� e/L ljglLrK Al do fifr i I'V4 a&3S Owner: &L—,NJ K--PA t1C%;4- 0V IF— Date of Inspection O/ Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes/ es No Pumping information was provided by the owner, occupant, or Board of Health. None of the system eompoaents.h&&% bean puarpe"ar-atJeast two weeks and-tbe'rystem hasba =ceilieg4vp sl Aow . rates during that period. Large volumes of water have not been introduced into the system recently or as part of this / inspection. ` ✓// _ As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. — The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. — All system components, excluding the Soil Absorption System, have been located on the site. Tne 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:- j Existing information. For example, Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)" 115.302(3)(b)] The facility owner (and-occupants.if different from_owner),were.provided.with ial[mmatioann th u. —m2aintenaQco.ef SASurface Disposal Systems. oi 1 r. I: revised 9j2/98 Page 5of11 SUBSURFACI SEWAGE DISPOSAL SYSTEM INSPECTION FORM Tl PART C SYSTEM INFORMATION 'I Property Address: CJLI�VC It /f/Q gt ey 6061144 0,1243S- 9 1 Owner: ©,eQ.1j it'.FCrI /JoQP2 Date of Inspection- �`/l ^ ♦♦ 30 -�I FLOW CON IX,] S RESIDENTIAL: `// Design flow':—A 4 U g.p.d./bedroom. MAY 4 1999 ~ Number of be/drooms(design): Number of bedrooms ►actual): N Mh Total DESIGN flow �j(J �0{iglOF Number of current esidents:i �i1LiH0 ,` Garbage grinder(yes or no):1AL0 _ Laundry(separate system) (yes or no&—_V If yes, separateinspaction required w Laundry system inspected.�yes or no) £ V Seasonal use(yes or no):/►O ,�mill �3 Water meter readings,if available(last two year's us:ye(gpd): � ��� Sump Pump (yes or n : Last date of occupancy: , COMMERCIAL/INDUSTRIAL: �F Type,of establishment: Design flo d ( Based 15,203) Basis of desig flow Grease trap pres t: (yes or no) Industrial Waste Ho 'ng Tan present: (yes or no)_ Non-sanitary waste dis gad to the Title 5 system: (yes or no)_ _ Water meter readings a ilable: Last date of occup cy: OTHER:(De ribe) , Last date f occupancy: GENERAL INFORMATION PUM ING RECORDS and source of information: System pumped as part of inspection: (yes or no) P.� If yes, volume pumped: 0 D gallons Reason for pumping: `I TYPE 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) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approv al Other n APPROXIMATE AGE of all components, date instalied{if known)-and source of•information: Sewage odors detected when arriving at the site: (yes or no),/—VO revised 9/2;98 . Page 6ofII • l SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) /Derte ress: �� ,eo�,f'P2 te'de 2�, e0/0,�� 1%d� A26 , aN ction:WER: (Locate on site plan) ,f Depth below grade:_ Material of construction: asy�ir n 40 VC_ other(explain) / Distance from private waty�r su p�y ell r suction line ` Diameter / Comments:(condition of joints,eventing, evidence of leakage,-etc.) SEPTIC TANK:_ (locate on site plan) Depth below grade:/ Material of construction:(/_concrete metal Fiberglass Polyethylene_otherlexplain) If tank is foetal,list age_ Jss.age-confirmed by Certificate of Compliance_ (Yes/No) Dimensions: 100 L — Sludge depth: it _ Distance from top of sludge to bottom of outlet tee or baffler Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle:�� How dimensions were determined: " -Iii e&5U&A—. Comments: (recommendation for pumping, condition of inlet and outlet tees or-baff es, depth of liquid level in relation to outlet invert, structureFintegrity, evidence of leakage, etc.) / GREASE TRAP: pocate on site plan) Depth below grade Material of construct n:_concr a _Fib glass _Polyethylene_other(explain) Dimensions: Scum thickness: Distance from top of scum to top f outl tee or baffle: Distance from bottom of scum to bo m of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pu ing, condition of inlet d outlet tees or baffles, depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage, a .) revised 9/2/93 Page 7ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C , SYSTEM INFORMATION(continued) /� Property Address: o g L2bc��� N � (..7o itk W-63SJ Owner: 6ed N Date of Inspection: . TIGHT OR HOLDING TANK: (TaZ1bed prior to, or at time of, inspection) (locate on site plan) Depth belo grade:_ Material of co truction: _concreteass_Polyethylene_other(explain) Dimensions: Capacity: ga s Design flow: allo /day Alarm present Alarm level: Alarm i\king : Yes_ No Date of previous roping: Comments: (condition of nlet tee, conditioloat switches, etc.) DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) — PUMP CHAMBER:_ (locate ite plan) Pumps in work g order: (Ye or No) Alarms in workin order es or No) Comments: (note condition of p chamber, condition of pumps and appurtenances, etc.) revised 9/-2/98 Pia;c8of11 • � j SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C / j, ,pSYSST�E,M INFORMATION (continued) Property Address:�:�C&dyllla� /�(�el� /CEC•, &k� % 11114 o.1&3S Owner: &,10 YL A,47�2i'Cld- Date of Inspection:'Y^30--9 1 SOIL ABSORPTION SYSTEM(SAS):_ (locate on site plan, is possible;excavation not required, location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits, number:_ leaching chambers, number:_ leaching ga leries, number:_ leaching trenches, number, length: leaching fie ds, number, dimensions: overflow cesspool, number:_ Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponds damp soil, condition of vegetation, etc.i CESSPOOLS:_ F (locate on site plan) f I r Number and configuration: Depth-top of liquid tc•inlet inv rt: Depth of solids layer: Depth of scum layer: f Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pu ed as part of inspection) - 4 Comments: (note condition of soil, signs of ydraulic fail e, level of ponding,.condition of vegetation, etc.) PRIVY:_ (locate on site plan) Materials of constructs n: Dimensions: Depth of solids: Comments: (note condition of Yoil, signs of hydraulic failure, level of p nding, condition of vegetation, etc.) revised 9/2/98 Page 9ofII s - r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM }� PART C p SYSTEM INFORMATION (continued) Prop"Address:a4p eategpe lueelc Owner: &a Ai r Pi¢%k 11 L! i Date of Ins �o�e2 pection: SO_99 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (kocate where public water supply comes into house) Cv n1 revised 9/2/98 I,J� 10 ofII 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM �? PART C n ' SYSTEM INFORMATION (continued) /�/L Property Address: �2�C�P2/� CSC /-d/ e0AQ ' 4 /)U Oo2�P 3 S Owner: .��Q/V Date of Inspection: / 3v-9� NRCS Report name Soil Type_ — Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water - Check Cellar Shallow wells Estimated Depth to Groundwater_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 Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) PD 4--Iov / revised 9/2/98 Page 11 or 11 x l6'CAT10,N y � SEWAGE PERMIT NO. orb C � , ,Quay VILLAGE r� n INSTALLER'S NAME & ADDRESS Ile �® U I L D E R OR OWNER �J DATE PERMIT ISSUED DATE COMPLIANCE ISSUED : Devi l No.. ............. F.Rs..SV.'............... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH (-.,PA41.Q............OF......... .A..J.:k.P.J. __`L...Ps-•e�--`._tr----------------•---- Appliratiou for %gpoiial Works Tomitrurtiou ranfit Application is hereby made for a Permit to Construct (/) or Repair ( ) an Individual Sewage Disposal System at: ...VO.T...2 G RoU G K f% N Fi G I� �p GDT U�.f.,....��!� Al5_�Pc P�C.� -F^'t•'��:--••................ - .. Location-Address or Lot No. D � i3o 4 r t�......... .6.�----�!�A!N..... r-•-•- GOB I l��/5.,__ .P�4� . ..M Vic::.............••-••--- -•---•-•- *--..._...... Owner Address Installer Address Type of Building Size Lot..._--7,Jl .....Sq. feet Dwelling—No. of Bedrooms.......................................................... _._...._..Expansion Attic ( ) Garbage Grinder ( ) a —Type g l^P-6 ...__..... No. of persons____________________________ Showers ( ) — Cafeteria ( )Other—T e of Building ___________ __ Q' Other fixtures --------------------------------------- - W Design Flow.............!........................gallons per person per day. Total daily flow-------------- ..................gallons. WSeptic Tank—Liquid capacity_106_I4P.gallons Length Width................ Diameter................ Depth................ x Disposal Trench—No. ...............I` Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No........l------------ Diameter......Io_**------- Depth below inlet...... ........... Total leaching area.�3_5:_jksq. ft. Z Other Distribution box (✓) Dosing tank ( ) Percolation Test Results Performed -D__ ! !z_►U.lGu.,4�54G.�Date.........................."___..._..__. aTest Pit No. 1....Ly._._mmutes per inch Depth of Test Pit----17........... Depth to ground water...N_0__ZJ.J=-__. 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 -------•-----•----------•------------•------••--••----------•-----•-----------------•--..._.........- O Description of Soil--------------- ..L.S. Ta PI��v S o iY=.. i =5 ..................................................` N t N D x w ---------------- -------------------------------------------------------------------------------------------------------------•-----.-----------------------------------------------................ U Nature of Repairs or Alterations—Answer when applicable................................................................................................ -- ------•--...•------•-••-••-•••-•-•-----••--------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iI'=- 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has een issued by the board of health. Application Approved By--------- ---- ----------_- ::. Z -.� _4---Da ............. Application Disapproved for following reasons---------------------------------------------------------------------•---------•--------------------------•----- ..............•--------------•-----------------------------•------------....---------.......--------•-----------------------------------------------•---•------------•--•----•------•-•---------------- Date Permit No...........................••-••---• Issued--•--•---•-------------------•....--•--.....--•-•••---- .................... Date No. : '. .. F zs..J, .............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH j`..r... -r-i.. .............OF.......... !.. ...r...:'J.`;._J....A 1 L r- Appliration for Uiipooal Worko Tonitrurtion thrutit Application is hereby made for a Permit to Construct (/) or Repair .( ) an Individual Sewage Disposal System at: ...L.� I Z. 6 f2 c c. V N G U V_ "2 GG j U l j �:1 ... tt/5.1_A 0,L ;^l .....-- ....... - ............. ........................................................ L,,ation-Address or Lot No. fJ G/A IJ G,l I2 4 r2 i M A I N �,i / _s�.; T.............................. � P�F c A/i -A- ..................... .: ............ ... - Owner ................................ ........ ............. ddress W Installer Address dType of Building _ Size Lot..C ------Sq. feet Dwelling—No. of Bedrooms.............................................................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building .... `J............. No. of persons............................. Showers ( ) — Cafeteria ( ) a' Other fixtures ................................. W Design 'Flow.................J.......................gallons per person per day. Total daily flow__._._.......__Jr..o...............•._gallons. 1:4 Septic Tank—Liquid capacity(, '`_gallons Length__`5!--2:_.. Width................ Diameter................ Depth................ Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. p ' 1 -- Seepage Pit No--------____--------- Diameter.__................. Depth below inlet-----.__............ Total leaching area.._.....--._...._.sq. ft. Z Other Distribution box ('�) Dosing tank ( ) '— Percolation Test Results Performed by. : t��: ......�!::%_��!.� a�'......_......G Date_....`.__.`G'. .`................ aTest Pit No. 1___G---___.minutes per inch Depth of Test Pit....1- -____-... Depth to ground water.. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ---------------------------------------------------------------------------------•----------....---......................................................... O Description of Soil...............x a U r' ( G AA ••• �. •-•---'--------------------------------•-•-•---- �� J •.........fi.--- w D U ---------------------------------------------------------------------------------------------------------------------------------------------------------------•-•--------...........-•••••......•-••--- UW ------------------------------------------------------------------------•------------------- --•---•-•-----------------------------............................................................... Nature of Repairs or Alterations—Answer when applicable............................................................................................... ---------------------------------------•--•........•. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TyT p 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance ,has �been issued by the board of health. Sigi ea---....................... .................................................... ...../�4.............. ....... Application Approved By.........'._.`":r.................................................................................. 2 / Date Application Disapproved for following reasons-------------------------------------------------------------------------------------------------------------.._ ----------------------------•-----------------------------------•-----------------------------------------•-••--••-••--•---•--•-•--•-------------•-•--••-•-•-----------•--••--•---------•--••-•....----- Date PermitNo......................................................... Issued_....................................................... . Date THE COMMONWEALTH OF MASSACHUSETTS " BOARD OF HEALTH ..........................................OF............. ................................................................ Trrfif iratr of Toutpliattrr 5-�r, E__T ERTIFY, That the Individual Sewag Disposal System constructed ( O'�or Repaired ( ) by - ....... ....... . p ......................:................................ .T•� � / � In taller ------------- T j of e. State Sanitary f a es�Pibed in the has been installed in accordance with the provisions of T I r f p m r, �- application for Disposal Works Construction Permit No--- ._, -r.. ........... dated_-_. ./� ._____.___--.-__•_-___-- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. . DATE........................................ ............... Inspector........................... -` 6 " • ------------------------•--...------------•--...-- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... No....................... FEE.......................... Dispogal Workii Tonotr ion rrutit Permission i erebY gra trd------� -V-141----------------------------- ,✓ - to Construct �'or Re >r ( ) a �,ndiv� Ztruction sal System at No.... -- .. .. = ' p ' Street as shown on the applicat' for Disposal Works Crmit No.____ __,.. Dated.......................................... r -----�------------------------------------------- -------- �' DATE...... -•�--�---------------•-----------•--------------...... Board of Health FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS a dJv .G lv l 0LiA,L_ ►-.s h.1 G. t� A `a'i L1:M,ts.D. f ti z,A 14:0, ,G.r. . { a L p R B :r.n 0;L L. Ql / PQp tp j ,'_-.--- tc dk rib GnTUt-r .,. 9AA TAALE , MA ��:,. � o0 i ZH Of A9gs�9 tis° w.' nn, M, w,a t2 rc.i 4 K T b-� , /`� �► `a g. WIWAM M. a o - � W6IRYVIGK No. 19771 . '. �4 �At SiE��®� eoc '� �� S U 94, �a r •� LEACHING 3,45IN ,SECNN NOT TO SCALE F I- 24 C.1.MH COVER EARTI/ FlL L r- BRICK AND MORTAR COURSES AS.Rag, TO BR/Nt COVER TO GRADE 4 b FLOW LINE l INLET i_ �;— •-' 2= TO WASHED PEAS TONE FgE.E OF IRONS, P/PE FINES AND D41sr IN PLACE a -`-` 1/: 4" TO /%2'�WASHED CRUSHED STONE FREf OF r OPENING r4'/TH.4%g" /RONS,'F/NES ANO OI/ST /N'PLACE Y OUTER D/ANET£R AND 1414"INS/DE • ' D/AA(ETER t I; CONCRETE TO BE 4000 PS ::2$ DAYS '1 2, REINFORCED WITH .6"x 6`i N0..6 GA, W.W.M, 3 1!AND 4! SECTIONS ARE AVAILABLE: FOR.'' GREATER;DEPTH. REQUIREMENTS . h' 'a; NUM9ER QF PITS REQUIRED M a lo' NOT£: EXCAVATEELEVATION TO _ 30 EFFECTIVE D/AMETEK T. T B OR. (NOT`TO EXCEfO J 2/MES fFFECT/Vf:DEPTH) 4OWER AS REQUIRED TO REMOVE ALL- • y --• - I.ArfR TABLE- -- :LOAM AND .,CLAY BENEATH PLT. REPLACE ;5 EXCAVATED MATERIAL WITH CLEAN # .Y TYP/CAL 'PROFIL£ GRAVEL,TO K SIGNED GRADE. IB"STD. LT. W6L C./.MN COVER !4"C.LPIl9E T!G OUTLfT LEVEL T.FIBER P/PE DWELL/NG FL000'LINf. NT JOINT TO f/R�^T✓DINT ,_..'^ /4N 00 TfE 40,5�J 1 I a 0 1 ! : 4a;t 111008 00 11 11 '�3 a 40.7o 'STD. PRECAST CONC.` 4 0.35 /ST. BOX TO BE 39• ' 1 1 0 0 0 00 1 1 1 I •;14W GAL.SEPTIC TAN INS ACLEO oN tEUE4, 1 lotico 000111 • STABLE BASF I .1 1 0 00 O.0 0 1 L I 1 11 000 00 1 1 1 P. Tr!CTA Af TOBf I i1000 00 O b INST444ED. 0#4EYE4, :i 10 O I O 0 1 0 1 STABLE BASE. � 11e00 O 0 1.1 , I ; i LEACHIN6 BASIN 11 0 Q O 00 BASE TO BE.LCVEL i t 1 0O I 1 1 , , EL,3¢6 . S014 AND.P£RC. DATA Z TEST PIT NO. p-- 3v2$ a TEST PIT NO.2 PERC.RATE MIN. /IN. Q To1o/4�0 to L O TEST BY ��✓�e N��v l5•� WITNESSED, BY: 4LEA.P.1 ntiEO<<JM TEST,PIT., EL, 4 z•o h A h } DATE. F5Es. - No .lm.Gto✓LJ A ✓AT �R DESIGN DATA GENERAL NOTES BEDROOMS 3 NO HEAVY .EQUIPMENT TO RUN OVER SYSTEM. DISPOSAL Ai ° 11J 0 SEPTIC TANK, DIST. BOX AN LEACHING BASINS TO BE STANDARD EST. TOTAL DAILY EFFL.33�GPD. PRECAST REINFORCED CONCRETE UNITS. SEPTIC TANK o o GAL. ALL .SYSTEM COMPONENTS SHALL BE INSTALLED IN ACCORDANCE . TO REVISED TITLE 5 OF THE STATE ENVIRONMENTAL CODE, SIDEWALL` AREA.LGAL./SQ.FT• MINIMUM REQUIREMENT$ FOR THE SUBSURFACE DISPOSAL OF BOTTOM AREA l.o' GAL./SQ.FT, y SANITARY SEWAGE EFFECTIVE ON JULY 11 1977. LEACHING REQUIRED L79. 1 SQ.FT,., ANY •CHANGES TO THIS PLAN MUST BE APPROVED BY. THE BOARD .' ACTUAL LEACHING AREA OF .HEALTH. �2 LieS.0.FT. AT -COMPLETION OF CONSTRUCTION, PRIOR TO BACKFILLING, THE• - BOARD OF HEALTH SHALL, BE NOTIFIED FOR INSPECTION. PITCH ALL SEWER LINES 1/40 / FT. UNLESS INDICATED OTHERWISE, 0.01i, SEWA W DISP05A L SYSTEM . MARTIN, .� MORAN r~i, o.T Z e(•e o F t�5 N E Il P o a C) •Via. � .p (123417�► � ._._..,.... U I 'C RD -A ,l -i t A 13 L_r A&,& 5�j . %GrrAl. �:•_�__- SCALE AS IN01CATEO WE �'e w�. 5 1���4• WX M. ,NWARWICK ®,.,ASSQC,, INC. : . ;Nora ,atOurrN PROFESSIONAL EWINEE/4 Massachusetts Water Resources Commission/Division of Water Resources WATER WELL COMPLETION REPORT WELL LOCATION �{ Address h OP r rjt City/Town CCY1ryl Iit !9 f G.S.Quadrangle Map Grid Location Owner_0 /t4r Nfff.�,.re1/ Address &Alry `07'a/I S ELL USE CONSOLIDATED WELL Domestic P ublic ❑ Industrial❑ Type of Water-bearing Rock Other Water-bearing Zones METHOD DRILLED 1) From To Rotary(type) Cable 2) From To Other 3) From To 4) From To L_ CASING Depth to Bedrock Length i�7 Diameter Type UNCONSOLIDATED WELL STATIC WATER LEVEL Water-bearing Materials, Feet below land surf ce Sand: . fine❑ medium❑ coarse[:] Date measured a Gravel: fine❑ medium❑ coarse❑ If Screen: usAsl— GRAVEL PACK WELL Slot _length JFfrom�to Yes ❑ No ❑ Split Screen(or 2nd"screen) WATER Q LITY TESTS MADK Slot# length from to Chemical [ Biological NK Depth To Bedrock PUMP TEST Drawdown _feet after pumping days hours at GPM. How measured Recovery feet after hours. LOG of FORMATIONS COMMENTS: (On well or water) Materials From To o n �n DRIL R D Fir /'{� t * AAI � Address4100 \ City Registration No. Fly perators Signature ease print firry y 10M-8/81-164843