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HomeMy WebLinkAbout0055 DOGWOOD LANE - Health E5Dogwood Lane 058 '1 I < <q-2. COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS [APR i F DEPARTMENT OF ENVIRONMENTAL PROTECTION A 1 7 RE MAR s•`` p 5 g 2003PARCEL ' - �0f DEPT. TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VC)L:JN'-'ARV ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 55 DOGWOOD LANE COTUIT 02 6 L9 k IS Owner's Name: VICTORIA GfORGANTAS O-'V Owner's Address: 55 DOGWOOD LANE COTUIT 2636 Date of Inspection:3/19/03 ►K_��J� VVV�" n Ube w. Name of Inspector: (please print) JOHN GRACI,INC. Company Name: SEPTIC INSPECTIONS Mailing Address: P.O. BOX 2119 TEATICKET,MA.02536 Telephone Number: 508-564-6813 FAX 508-564-7270 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address a::d 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 DE.P approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: X Passes _ Conditionally asses _ Needs Furth Evaluation by the Local Approving Authorty Fails Inspector's Signature: Date: 3>19/03 The system inspector shall submit copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspec n. 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 THE SYSTEM PASSES TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. ****This report only describes conditions at the time of inspection and widen tt.e conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Titlr 5 incnPrtinn Fnrm A/1 VM00 1 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 55 DOGWOOD LANE COTUIT 02636 L9 Owner: VICTORIA GEORGANTAS Date of Inspection: 3/19/03 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. 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. n/a The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *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: n/a n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): _ broken pipe(s)are replaced _ obstruction is removed _ distribution box is leveled or replaced ND explain: n/a n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): _broken pipe(s)are replaced _obstruction is removed ND explain: n/a Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 55 DOGWOOD LANE COTUIT 02636 L9 Owner: VICTORIA GEORGANTAS Date of Inspection: 3/19/03 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 n/a "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: n/a Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 55 DOGWOOD LANE COTUIT 02636 L9 Owner: VICTORIA GEORGANTAS Date of Inspection: 3/19/03 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for alLinspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _ X Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow _ X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped 611102 BORTOLOTTI. X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP 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.] �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 Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 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. Q Page S of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 55 DOGWOOD LANE COTUIT 02636 L9 Owner: VICTORIA GEORGANTAS Date of Inspection: 3/19/03 Check if the following have been done.You must indicate "yes" or"no" as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks? X _ Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out? X _ Were all system components,excluding the SAS, located on site X _ Were the septic tank manholes uncovered, opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid, depth of sludge and depth of scum? X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no X _ Existing information. For example,a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 55 DOGWOOD LANE COTUIT 02636 L9 Owner: VICTORIA GEORGANTAS Date of Inspection: 3/19/03 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 4 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 548 Number of current residents: 1 Does residence have a garbage grinder(yes or no): NO Is laundry on a 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)):r--�'� �� Sump pump(yes or no): NO t Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: 6/1/02 BORTOLOTTI Was system pumped as part of the inspection(yes or no):NO If yes,volume pumped: n/agallons--How was quantity pumped determined?n/a Reason for pumping: n/a TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _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): n/a Approximate age of all components,date installed(if known)and source of information: 1985 INFO FROM PLAN Were sewage odors detected when arriving at the site(yes or no): NO F Page 7 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 55 DOGWOOD LANE COTUIT 02636 L9 Owner: VICTORIA GEORGANTAS Date of Inspection: 3/19/03 BUILDING SEWER(locate on site plan) sI Depth below grade: 33V Materials of construction:_cast iron X40 PVC_other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade:30" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: L 8' 6" H 5' 7" W 4' 10"" Sludge depth: 0" Distance from top of sludge to bottom of outlet tee or baffle: 34" Scum thickness: 1" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 17" How were dimensions determined: MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): SEPTIC TANK AND ALL SEPTIC TANK COMPONENTS ARE STRCTURALLY SOUND AND FUNCTIONING PROPERLY.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. GREASE TRAP: _(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): n/a Page 8'of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 55 DOGWOOD LANE COTUIT 02636 L9 Owner: VICTORIA GEORGANTAS Date of Inspection: 3/19/03 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX: X(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE 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.): D-BOX IS STRUCTURALLY SOUND.-SYSTEM SHOWS NO SIGNS OF FAILURE. PUMP CHAMBER: _(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber, condition of pumps and appurtenances,etc.): n/a R Page 91 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 55 DOGWOOD LANE COTUIT 02636 L9 Owner: VICTORIA GEORGANTAS Date of Inspection: 3/19/03 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type 1000 GAL 6' X 6' leaching pits, number: 1 n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a innovative/alternative system Type/name of technology: n/a Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation,etc.): THE LEACH PIT IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.THE PIT HAS 2' OF STONE AROUND IT.THE PIT HAD 1' OF WATER IN IT AND NEVER MORE THAN 2' INDICATED BY STAIN LINES. BOTTOM IS AT 91-SYSTEM SHOWS NO SIGNS OF FAILURE. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a A Page.10 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 55 DOGWOOD LANE COTUIT 02636 L9 Owner: VICTORIA GEORGANTAS 'Date of Inspection: 3/19/03 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 buildi:ig. w _ A c 13 I . 0 b AP AC '31 AQ 3� PA in f 'Page 1 1 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 55 DOGWOOD LANE COTUIT 02636 L9 Owner: VICTORIA GEORGANTAS Date of Inspection: 3/19/03 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 12+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) YES Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: GROUNDWATER DETERMINED FROM HAND AUGER AND USGS DATA-NO WATER AT 12' it AS-BUILT L0CAs' ION SEWAGE PERMIT NO. 55 Lot g Dogwood Lane 85-662 T i LL L A C. E Cotuit � INSTA LLER'S NAME A ADD9ESS William Bonito P.O. Box 112, 'E. Falmouth, MA_ 02536 Polcaro ,Construction Co.__ D. ATE PCHW, IT ISSUE -D' 12 n DATE CC IPLIANCE ISSUER LOT AS-BUILT 0fAT !ON SUNASE PERMIT NO. ��` " 55 Lot 9 Dogwood Lane 85-662 Cotuit NIKSTA LLER'S H A M E A AD09ESS c� William Bonito P.O. Box 112, E. Falmouth, MA 02536 IMI UILD.E. R on 0tv,"E"a r 0 Polcaro _Construction Col T E P k I: �# I T 4 S S U to DATE CItVIPLIANCE ISSUED LOT D us 'Jxa�woara a..p�� � THE COMMONWEALTH OF MASSACHUSETTS MAP BOARD OF HEALTH � PARCEL �n oW-te'1... oF....... .t .5.. C- l-_ ..........LOT Appliration for Dhipos ai Works Tonstrurtion Prrutit Application is hereby made for a Permit to Construct (L,,)"'or Repair ( ) an Individual Sewage Disposal System at: ..... . ' S `LD .�.,�o .......L-.A1'E L o� -- - -.... _ ----------------------- ........ Location-Address ,F©L:5 1A&1-.....001 . .+.00.:1...+ 1� ...I..VRT.� ...M lAul®NS .1 1L1 . Owner Address . W �L a •-•---•-----•.................••-----•-------------•---•---••-•-••---......_.....------.....----- Installer Address d Type of Building Size Lot... 4�33- ...Sq. feet DwellingU. No. of Bedrooms._.._.__.. _ _Ex ansion Attic— .--------•-------•--•----. P (�D) Garbage Grinder (�®) aOther—Type of Building _.......A.............. No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures --------------------------------------------------------------------------------------- ------------------------------------------------•------------ W Design Flow............?5..5........................gallons per person per day. Total daily flow........3 3 0...__. ............. W Septic Tank—Liquid capacity.1PPO-gallons Length..�� `'.. Width4'-10.". Diameter-_/A--_. Depth.5..-:-.V'_. x Disposal Trench—No.,___01A....... Width.................... Total Length......._............ Total leaching area....................sq. ft. Seepage Pit No--------I------------ Diameter......LP........ Depth below inlet......G......... Total leaching area..7;?��; ....sq. ft. Z Other Distribution box ( e ) Dosing tank I,o) ~' Percolation Test Results Performed by................ o._. _U_.L-'__�.........._............ Date---mAx...j.6 n84- } `�' d Test Pit No. 1._._.�_._._.minutes per inch Depth of Test Pit._____.��-_�..___ Depth to ground water...Q__.._�.l9.Co>.�h eVe fY4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 ----•-•------------------- - ................. ............--------•-----•••-•--•--------•-•---.••---............-- Descrl Description of Soil �b �� - '� 0 f °�$ezd v - ---------------------------------------- +.s° 10 1 z° e���,�..__ e s' � , ��_�a�1� x ------------------------------------------------............................................................. �� II ----- --- U Nature of Repairs or Alterations—Answer when applicable.___.1�1 ___A............................................................................. ..............-......................................................................................................................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITI1 5 of the State Sanitary Code—The undersigned further agrees not to place the system in opera ioq 1 a Certi- to of ce has been issued by e board Of al Signed ° -•----..... .••.• •----------- D pplication Approved By.......... .. . l ate Application Disapproved for the o Towing reasons:......................................................... ....................... -----------------------------•---•-••--......._....--------...-----------....-------------•-•-----.....-------•--........----------------------------------------------•----- ......................... Date •y�� PermitNo......................................................... Issued-----••-----------Dattee- ................................ - - ---- � N} � •.may'"-,.`.. No................-....... FEB.............................. THE COMMONWEALTH OF MASSACHUSETTS —�'-� BOARD OF HEALTH ►.. .1 014 --....OF........ .............. Applirtation for Biiipoii al Workii Tonitrurtion lirrutit Application is hereby made for a Permit to Construct (L,15`�or Repair ( ) an Individual Sewage Disposal System at: ---------------�........_.. . ?. , p ?�'�------•-.....!......►.�--... ................................................ .. ......... Location-Address or Lot No. ,PQ LC.A- 0 - �5':.C. :._6. ��. .:....... 1 7 a �1i�. _k�ALl� s`�--.c�t,6R�i _o>`( Owner Address (' W Installer Address Q Type of Building Size Lot....--_....4...................Sq. feet U Dwelling—No. of Bedrooms........._�.............................Expansion Attic (40 Garbage Grinder 6o) p`4 Other—Type of Building ..N-/A.............. No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures ............................ . W Design Flow.......... __________________________gallons per person per day. Total daily flow...----- -C-------_....__.____._.___gallons. {�{ _ 1` 1( WSeptic Tank—Liquid capacity E�©9_gallons Length_�_-!�`_. Width•.f-r�__-.l�.... Diameter_!.`_!/A__._. Depth�.__.7..... x Disposal Trench—No. _.J 1_A........ Width.................... Total Length.............-...... Total leaching area....................sq. ft. Seepage Pit NO........I------------ Diameter-----1_ . ...... Depth below inlet.._..?_. _�....... Total leachingarea.. -�.C�_...sq. ft. Z Other Distribution box Dosing tank (No)� ~' Percolation Test Results Performed by............... .................t _ -_�__A`..__.._................. Date__ _ ___.i ? y' ' f-- ------- �a Test Pit No. I.._..���''-_•__-_-__minutes per inch Depth of Test Pit...... ....... Depth to ground water_142 s_.. i;. �u pi e.✓<'(.` Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ._......... ........ •• --- --------------- -----------------------------•-- --------------•----------- Description of Soil...........` 1 ....... .......... ' -•..-u- -„?l V ........................... I .............................................................-----------------------------I--•--•••----•-----------•----•------•-----•-----------•---------•••----•------------------------------------ U Nature of Repairs or Alterations—Answer when applicable...._KJ_A__________________________________•-_--_______---__-_-__--•--•--•--•----_--__. ..-• •••••-••--•-•-••••--•••--••-•--••-•-•-••--•••••-•-••••----•---•-•-•--••....-••----•--------•-•---•--••••••-•-...---•--•••--•-•••--•---•••--------•--•-••••--•--•--•--•••-•-. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITILE 5:of the State Sanitary Code—The undersigned further agrees not to place th'e system in oper ioli it a Certifi to OILd=pliance has;been issued by 1he board of eal . f Signed. ... . D QC PPlication Approved By•....-- •-•--- .......................... ........ .. .... �.d----•- ate Application Disapproved for the f Rowing reasons---------------••-----------. .................--------•----•----------------------------------------.......---- ..............................................................................----------------....-----•-------••-•-------•-•--......-•--•--•---•-----------••---•-••--•-••-------•••......---......_. Date PermitNo......................................................... Issued....................................................... Date ' THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF......................................I.......................I...................... (9rdifirFa#r of Tootplitanrr THIS IS� CER FY, That the Individual Sewage Disposal System constructed�(�or Repaired ( ) by--------------------J •-, OAZI.X....Q....................... .------ •-------- --------------------....------.......------------..............-- / Int ll ...............' A)......... e ...............Y•7� .._r............................................ at - ► has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No------ ..... dated---------- ............. THE ISSUANCE OF THIS.CERTIFICATE SHALL NOT BE CO STRUE® AS A GUARANTEE THAT THE 4v SYSTEM WILL FUNCTION SATISFACTORY. DATE.....:..... M '°JAI ................................. Inspector........ • .. ---------------------._.:. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No..5-4.6 _ ..........................................OF............................. FEE.M._-• ... 'Dispaga1 Ivor ii �ondra ion ami# Permission is hereby granted. wM' t �{/,/ = - --------------------------------•--.....-- to Construct ( or Repair ( an I divldual Sewage Disposal System as shown on the application for Disposal Works Construction Permit Street $$``�'? •Dat d....._.7 _ _ _ ......... Board of Health FORM 1255 HOBBS & WARREN. INC.,' PUBLISHERS , -ter � 1"` •• -- , Finish grade above and adjacent shall slope a min.of 2%oway from system p 4 diam. cost iron or Schedule 40PVC pipe (tight joints). ' LOT I L 0 T 8 p 20 min. distance ( building to edge of leaching system ) 1 PL. BK.282 PG.27 0000 IO�min.dirt. S4toke 269.19 i Stoke !6 T 43 � 6,61 Access over set ,� L O T / 9 / o First Floor EIev.=50.50 within 12 of finish grade. 54, 328 t S. IF O ►, Finish rod „ I cv� e. �. ° 1 . !� ~LOT. 12 mate. S-Q,Q2 - Remova ble covers Removoole O 7 cover I- 2 + $-0. 2 O �+ t 86 N. S;Q2 - Clean bock N 130- , ed .° Liquid level level 1 I to d 03. 2"layer of!V to /2' cd P U g E — .. }'�- o°°o'do. O '. o 0 0 o co �000•• washer stone. — 2�' 50 N — DIST. ° • t u W Do N z Test hoc. / �! �� ;. e• I` Q1 BOX a�8 0 0 o o 0 o o o o c d ap W N.v �: \4 ! �32 ��Qto ol. v SEPTIC TANK ' rn cJ N c o 0 o o ,°2'• N Hole o ! �•`0p0 (ANK'� - D . a V N Effective °° �' Y w O�.�vewoY 20 . J�e�$E�eCf � deep _ 1000 GA L. _ d 6' .a m N .a It Depth �9 a d a 62 Q 0lS'V ,oR` x6 pCC 0 0 0 0 0 0 0 o S _, fake r a > _- n' 3 °o Precast concrete :°° s �, r � —0. , Foundation c c o S.e LEACHING PIT °Oo goo �_ Design — — .EIev.=38.0 Yd By others PROF I L E -2ft•'}--6ft.diameter — 2ft,d 4 DESIGN CRITERIA Not to scale 2 ft.of /4'to I/2"woshed stone 4,6� 2 Wa�Ve all around precast pit providing aP 1 effective diameter of 10ft. El.= 33.4 N NUMBER OF BEDROOMS 3 (equivalent to 330 gals/day). '� cw GARBAGE DISPOSAL UNIT NONE Bottom of test hole iQ6 v _ LEACHING AREA-CAPACITY REQUIRED 330 gals/day- GENERAL -NOTES OO BENCH MARK Stake / V`I O SIDE AREA PROPOSED 188 Sq. Ft. G Hydrant spindle I )NOCHANGE TOTHISSYSTEM SHALL BE MADE UNLESS. r1 O BOTTOM AREA PROPOSED 78 Sq. Ft. APPROVED IN WRITING BY HOLMES and McGRATH, INC ��3 ? EIev=5Q00(ossigned) TOTAL AREA PROPOSED 266 Sq. Ft. 2)SUBJECT TO INSPECTION DURING CONSTRUCTION BY o THE BOAR DOF HEALTH AND HOLMES and McGRATH,INC. PROPOSED LEACHING CAPACITY 548 gals/day . 3) HEAVY CONSTRUCTION EQUIPMENT SHALL NOT TRAVEL �� r OVER DISPOSAL SYSTEM DUR ING OR AFTER CONSTRUCTION. WATER SUPPLY TOWN SYSTEM 4) DISPOSAL SYSTEM TO BE CONSTRUCTED IN ACCORDANCE c PRECAST CONCRETE UNITS H-10 LOADING DESIGN. WITH TITLE 5 OFTHE STATE ENVIRONMENTAL CODE. 5)A COPY OF THESE PLANS MUST BE KEPT ON THE SITE BENCHMARK: HYDRANT SPINDLE EL=50.00(As signed) . DURING THE TIME OF CONSTRUCTION . - � 6)A COPY OF THESE PLANS MUST BE FURNISHED TO THE SOIL LOG CONTRACTOR CONSTRUCTING THE DISPOSAL SYSTEM. 7) BEFaRE BACKFI LLING,TH E CONTRACTOR SHALL NOTIFY HOLMES and McGRATH,INC. OR THE BOARD OF HEALTH N- I N- 2 AGENT TO INSPECT THE SYSTEM AS CONSTRUCTED. Depth Soi Is Elev. Depth Soils Elev. 8) FLOOD PLAIN HAZARD ZON E C 0' 45.4 9) ZONING DISTRICT R F DATE D E S C R IP.T10N Drown by Checked by LOA M, 10) THE NORTH ARROW IS DERIVED FROM RECORDED PLANS SUBSOIL OR DEEDS. THE NORTH ARROW SHALL NOT BE USED REVISIONS 43.9 FOR ORIENTATION FOR SOLAR HEATING PURPOSES. HOUSE PLOT PLAN II) S01L TEST APPLICATION # P 3341 _ N° Clean 55 OF PROPOSED SEWAGE DISPOSAL SYSTEM 1tiy �� FOR POLCARO CONSTRUCTION CO. INC. d�- A T P.OBER /� BuxiG � COTUIT= i4RNSTABLE , MASS medium S01 L TEST TITLE_ REFERENCE: Sand, LOT 9 DOGWOOD LANE n ^ AE„ �. DATE OF SOIL TEST MAY 16. .1984. B �� N ,5 — Gravel . TEST TAKEN BY D. THU L I N L.C. Pet. Plan 39660 B SCALE: I 50 DATE: JULY 9, 1985 RESULTS WITNESSED BY G I FFOR D holmes and mcgrath�inc. civil engineers and land surveyors 4 PERCOLATION RATE_� MIN./INCH. 200 main street � \IVI GROUND WATER NOT ENCOUNTERED ASSESSOR folmouth, ma. 02540 Checked CS MAP N° 25-58 ? 548- 3564 JDrawn by R.S.J. JOB N2 8M3 DWG N° A 1516 SHEET I OF 2 Alloutlet pipes from the distribution box shall be set level for at least 2'from the box. i OUTLET KNOCKOUTS ALTERNATE ALTERNATE INLET OUTLET ( � INLET OUTLET;- F 2-6 7 _j OUTLET 1 (� KNOCKOUTS INLET -► �_ii, ;^ t� �� OUTLET P LA N I 4 -10, L 2'—6-. P L A N 2'-6 � Conc. cover I ( I I All access manhole covers for septic tank, 1­1 L I distribution box and/or leaching system Li shall havecovers set within 12'of finish ALTERNATE ALTERNATE gradeor as directed bytheinspecting ?' °Q 2'-3" INLET ofz:z�o OUTLET outhority . INLET --*- OUTLET - Metal from 8&cover or STEEL REINFORCED PRECAST CONCRETE precast concrete cover: ;�` fi'min�n 4" OUTLET KNOCKOUTS 4 .e �. �.6. r7 7, op 9'-0 8'_6" Precast concrete riser, SECTION ELEVATION " concrete block or 3" 3'tj �-- brick masonry. TYPICAL PRECAST CONCRETE DISTRIBUTION BOX --Removable covers r_jSCALE o �4 I /2 = 1=0 a• e, v rl f_ 32 min.clearance requi.red•• � INLET 'min.inlet to outlet 5 min. Tee V UTLET 10'min. -Liquid level-• -14 = _ 6_0 _ 5-7" �- 4'-0" DATE DESCRIPTION • Drawn by Checked by 4- . min. — REVISIONS min. -' PLOT PLAN — DETAIL SHEET ' - — - OF PROPOSED SEWAGE DISPOSAL SYSTEM' OF 6 7K FOR POLCARO CONSTRUCTION CO.INC. •. • �'3" � WABSR o -� LOT 9 DOGWOOD LANE ELEVATION SECTION CROSS SECTION COTUIT BARNSTABLE, MASS. BUR ' N42 y TYPICAL 1000 GALLON SEPTIC TANK/: H•10 LOADING SCALE: n shown DATE: JULY 9, 1985 holmes and mcgrot h,inc. Ay 15TEA�`c� SCALE: 3/8" = I'-0" civil engineers and land surveyors ; g� j 200 main street iaN NOTE : ''� DENOTES DIMENSION' OF H —20 LOADING DESIGN falmouth,mo.02540 checked b 548-3564 1 Drawn by R.S.J. JOB N215 33 F, DWG.Ns SHEET 2 OF 2