HomeMy WebLinkAbout0079 DOGWOOD LANE - Health 79 Dogwood Lane
A_= 025-055
TOWN OF BARNSTABLE nn
LOCATION h �( UU SEWAGE# �J
VILLAGE 'k '7 ,-ASSESSOR'S MAP&PARCEL.
IN NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) 1 1 (size)
NO. OF BEDROOMS 3
.OWNER
PERMIT DATE: CO DE DATC�V%c7p 1�
Separation DistanceBetween the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility feet
Private Water Supply Well and Leaching Facility(if any wells exist
on site or within 200 feet of leaching facility) feet
Edge of Wetland and Leaching Facility(if any wetlands exist
within 300 feet of leaching facility). feet
FURNISHED BY
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OWN OF BARNSTABLE
LOCATION L07,*:( �,�.✓��<;� / SEWAGE #
VILLAGE CaTyi 71--- ASSESSOR'S MAP & LOT 6 -®ce's
INSTALLER'S NAME & PHONE NO. ;}�t��, A d //
SEPTIC TANK CAPACITY
LEACHING FACILITYAtype) (size) MeL/
NO. OF BEDROOMS PRIVATE WELL OR UBLIC WA
/BBU_ILTDERI OR OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED: 93,
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VARIANCE GRANTED: Yes N
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Commonwealth of Massachusetts
W Title 5 Official Inspection Form
- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
79 Dogwood Lane
Property Address
Barbara Stevens
Owner Owner's Name
information is Cotuit MA 02635 - _ .September 17, 2008
required for - — ------ -- -- - -----
every page. City/Town- State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way,
Important: A. General Information
When filling out
forms on the _
computer,use 1. Inspector: I
only the iab key
to move your Patrick M. O'Connell _ _ _ __ _ 02.5—055
cursor-do not Name of Inspector
use the return
key. Septic Inspection Services Co.
Company Name
rae 189 Cammett Road
Company Address
Marstons Mills MA 02648 _
eum City/Town State Zip Code
-- 508-428-1779 SI12855
Telephone Number License Number
B.-Certification
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 the inspection. Tte'insp,Ection
was performed based on my training and experience in the proper function and Mal. tenanceof on site
sewage disposal systems. I am a DEP approved system inspector pursuant t`i
ection 1.5�3401of
Title 5 (310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fai s c?
❑ Needs Further Evaluation by the Local Approving Authority
- T Se tember 172 2008
• Insp ctor's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or
has a 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.
****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.
V - I !7
•Pa e1of 15
08-244 Stevens.doc•08106 Title 5 Official Inspection Form Subsurface Sewage Disposal System g
y
' S
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
79 Dogwood Lane
Property Address
Barbara Stevens ---------------- --- ---------- --
Owner Owner's Name
information is Cotuit MA 02635 September 17, 2008
required for — -------- ----- --- -- ---- -
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E / always complete all of Section D
A) System Passes:
® 1 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:
Tank is not in need of pumping at this time, leaching system-is functioning properly.
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 breakout 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
08-244 Stevens.cloc•08/06 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 2 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
.'' 79 Dogwood Lane
Property Address
Barbara Stevens
Owner Owner's Name
information is required for Cotuit MA 02635 September 17, 2008
--.-.--- — —
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ distribution box is leveled or replaced
ND Explain:
❑ "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:
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.
08-244 Stevens.doc•08/06 Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 3 of 15
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
79 Dogwood Lane
Property Address - - ----- ------ ----- ------ -- -
{ Barbara Stevens
Owner Owner's Name
information is required for Cotuit MA 02635 September 17, 2008
-------- -------- - -----
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cont.):
❑ 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 indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or "No." to each.of the following for all inspections:
Yes No
El ® 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
El due to an overloaded or clogged SAS or cesspool
El ® 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
a than _day flow
El
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.
08-244 Stevens.doc•08/06 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 4 of 15
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
79 Dogwood Lane
Property Address
Barbara Stevens _-
Owner Owner's Name
information is required for Cotuit MA 02635 September 17, 2008
--- - -- -
every page. CityrFown State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply
well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory, for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the
questions in Section D.
Yes No
I
❑ ❑ 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.
08-244 Slevens.doc•08/06 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 5 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
79 Dogwood Lane --- ------------ -- -------------
Property Address
Barbara Stevens
Owner Owner's Name
information is Cotuit MA 02635 September 17, 2008
required for
every page. City/Town State Zip Code Date of Inspection
C. Checklist
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?
Z ❑ 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)
N ❑ 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
21 ❑ 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:
❑ Existing information. For example, a plan at the Board of Health.
El approximation
in the field (if any of the failure criteria related to Part C is at issue
21 approximation of distance is unacceptable) [310 CMR 15.302(5)]
08-244 Stevens.doc•08/06 1itle 5 Official Inspection Form.Subswiace Sewage Disposal System•Page 6 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
79 Dogwood Lane
a —
Property Address
Barbara Stevens
Owner Owner's Name
information is required for Cotuit MA---- 02635 September 17, 2008
---.--------- -- ---- -
every page. Cityfrown State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 --- Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
2
Number of current residents: - —
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ® No
100,000 gal. _
Water meter readings, if available (last 2 years usage (gpd)) 136 gpd.
Sump pump? ❑ Yes ® No
Last date of occupancy: Currently
p y Occupied
Commercial/Industrial Flow Conditions:
Type of Establishment: --- - ^-- -- - —
Design flow (based on 310 CMR 15.203): a;lons per day(gpd)
Basis of design flow (seats/persons/sq.ft., etc.): --
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available: -
Last date of occupancy/use: Date
Other(describe): __.......-------- -------------- --- - -- -- -.._.. _ - ------------------
08-244 Slevens.doc•08/06 title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 7 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
_ 79 Dogwood Lane
Property Address
Barbara Stevens
Owner Owner's Name
information is Cotuit MA 02635 September 17, 2008
required for — ---
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
General Information
Pumping Records:
Source of information: Tank pumped 8/13/07__
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined? —
Reason for pumping:
Type of System:
Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
[] Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract (to be obtained from system owner.)
[] Tight tank. Attach a copy of the DEP approval.
❑ Other (describe):
Approximate age of all components, date installed (if known) and source of information:
14 years
Were sewage odors detected when arriving at the site? ❑ Yes X . No
08-244 Stevens.doc•08/06 7ale 5 Official Inspection Form Subsurface Sewage Disposal System•Page 8 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
79 Dogwood Lane
Property Address
Barbara Stevens _
Owner Owner's Name
information is required for Cotuit MA 02635 September 17, 2008
---
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer (locate on site plan):
Depth below grade: feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain): ---
Distance from private water supply well or suction line: feet'
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank (locate on site plan):
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
------------------------------------------------ --------- ---------------------------------------------
Dimensions 8.5' long xy5.2'wide_1000 gal.
2"
Sludge depth: -- ---
Distance from top of sludge to bottom of outlet tee or baffle 28
Trace
Scum thickness
6
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle Measured
--
How were dimensions determined? Mea Mea ured -----
08-244 Slevens.doc•08106 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 9 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
/V 79 Dogwood Lane
Property Address
Barbara Stevens
Owner Owner's Name
information is Cotuit MA 02635 September 17, 2008
required for -- - -
every page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Liquid level was found at bottom of outlet invert, baffles are intact and clear__
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions: --
Scum thickness
Distance from top of scum to top of outlet tee or baffle - ---
Distance from bottom of scum to bottom of outlet tee or baffle ------ ----
Date of last pumping: Da 1.te -
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
Liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade: --- — —
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
08-244 Slevens.doc•08106 Title 5 Official Inspection Form,Subsurface Sewage Disposal System•Page 10 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°•�a� P 79 Dogwood Lane
Property Address
Barbara Stevens
Owner Owner's Name
information is required for Cotuit MA 02635 September 17, 2008
-------------- ---- — — ---
every page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Tight or Holding Tank (cont.)
Dimensions:
Capacity: gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: — -------- Alarm in working order: ❑ Yes ❑ No
Date of last pumping: date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
Distribution Box (if present must be opened) (locate on site plan):
0°
Depth of liquid level above outlet invert - - - - -`- - -- -
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.):
No solids or high stains present, liquid level at bottom of both outlets.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
08-244 Stevens doc•08/06 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 11 of 15
Commonwealth of Massachusetts
/72
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
79 Dogwood Lane
Property Address
Barbara Stevens
Owner Owner's Name
information is Cotuit MA 02635 September 17, 2008
required for --- ----- -- — —----- -
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
® leaching pits number: Two 600 gal pits.
❑ 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.):
One leaching pit had no standing water with no high stains, other pit was not opened_
08-244 Stevens.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
79 Dogwood Lane
Property Address -------------- ----------
Barbara Stevens
Owner Owner's Name
information is required for Cotuit MA 02635 September 17, 2008
_._.
every page. City/Town State Zip Code__ Date of Inspection
D. System Information (cont.)
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration -----
Depth-top of liquid to inlet invert --------- —
Depth of solids layer --- -
Depth of scum layer --- --------
Dimensions of cesspool —
Materials of construction --------
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction: -----------_._._._._._..............._.___-._._._.._.____--___-.._ —__—
Dimensions -- ------------------ ---
Depth of solids ------.._..---- ------- -----
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
08-244 Stevens.doc•08/06 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 13 of 15
Y Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
\ % 79 Dogwood Lane
Property Address
Barbara Stevens
Owner Owner's Name
information is Cotuit MA 02635 September 17, 2008
requiredfor _............ p- -------._...._..... ----------------- ...
every page. City[fown State Zip Code Date of Inspection
D. System Information (cont.)
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.
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Commonwealth of Massachusetts
a Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
79 Dogwood Lane
i e
Property Address
Barbara Stevens
Owner Owner's Name — -------.__.._.._.—_..------..----.._—._...-----------------
information is Cotuit MA 02635 September 17, 2008
requiredfor ------.-_._..-:..._.. . _._....-----..... _.._................
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to ground water: 12+ - —
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: 10/17/93
Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health - explain:
❑ Checked with local excavators, installers -(attach documentation)
❑ Accessed USGS database - explain:
You must describe how you established the high ground water elevation:
Perc test performed on 5/16/84 found no water at_144". _ _-__—
i
08-244 Stevens.doc•08106 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 15 of 15
THE COMMONWEALTH OF MASSACHUSETTS
373-5 BOAR® OF HEALTH
OW.f OF......S .,. �J���..1.' ! a_�. ......................
AppAration for Bi-quil at Workii Tnnitrnrtinn ramit
Application is hereby made for a Permit to Construct r Repair ( ) an Individual Sewage Disposal
System at: C& "r 1
.... _..... .0 c�,�. ..... ----- ----•-----••- f..................................................................
t L c tion-:ddress r t Now
.._ 5. „T--------------------•------------..... tom/ {-IM.Q�?
Ow er ddress J-•- r
a �°G�H /� ! o lHN tS ills
Installer Address
Type of Building Size Lot__Gqt...s0_(a_. q. feet
U Dwelling—No. of Bedrooms__ Expansion Attic ( ) Garbage Grinder ( )
Oiher—Type of Building ............... No. of persons_....................__.____ Showers — Cafeteria
Q' Other fixtures .................................................... ---------- ------------
-•----------
W Design Flow...... .....:...............gallons per person pej d . Total d '1y flow__..._..3c 0.._.... ............gallons.
WSeptic Tank—Liquid capacity/400.gallons Length._.=�... Width../_��lS~Diameter________________ Deptl7._7....
x Disposal Trench—No..................... Width..�.....��....... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No._. ., .�_.. Diameter.._lU�.... Depth below inlet. ...7...... Total leaching area..J. 21.Z..sq. ft.
Z Other Distribution box .(Vr Dosing tank ( )��,� r,
Percolation Test Results Performed by._VAU0.....-1.—L,1_�.a7_......p,6............. Date...._ 6_:�.._..._.
a --
,a Test Pit No. 1...2......minutes per inch Depth of Test Pit........JZ�... Depth to ground water.._.l�lA/ .._.
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a. -
0 Description of Soil- -� 'U/ QGL 1
x
W ••-•••••••-•-----•-----------•-•-------•---•---•------••-•-•------------•-•-••--•-•-•--•••--•---....----•-----••--------•-•-----••-•---------•--•------••••••--•-----•-•••••......•••...............••--
UNature of Repairs or Alterations—Answer when applicable..............................................................................................."
----------------------------•-----------------------------------------------....------......----•-...---••-•--------------------------------------•-------•------------------------------------•---••••.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Complia has been issued by the b and of health.
Signed --------_-- - ------------ .............................. ...../ .$�..
Dare
Application Approved By -............0 .. S�V -- -° ------------------------------------------------------------------------ ----------`e�e..�-.J...�--"
� +1
Application Disapproved for the following reasons: .. ................... .................. ............................ .... . . ... ..........................
---------------------------------------------------------------- ----- -------------------------------=------------------------------- ------- -------------------------------------------------- ----------------------------------------
Permit No. -------9 --------Ik--��-�........... .......... Issued -.-------------. .-. ........
.....----..
Date
5-
No......................... Firs..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD. OF HEALTH
. F-
-----......[OW --.....OF.....
OAZ05-1...A.Q�.CT.......................
Appilration. for Uhipaiial Workgfunstrurtion ramit
Application is hereby made for a Permit to Construct V4—Or Repair an Individual Sewage Disposal
System at:, ce,7�T,f
...............................a...............................................................
........... ......Lrli� . . .....
f A c lionj�d� ss A A
....................................... ...
•
QQPe U
.... ......... . ....... ..... ...... .... ............. .....
0 dr s.s. j1
.....................
11_291�ad;p................................. ... ...........
Installer Address 4-
Type of Building Size _0*?'7Sq. feet
U X
Dwelling—No. of Bedrooms-_-._,=..................................Expansion Attic Garbage Grinder ( )
'_l
P4 Other—Type of Building ............................ No. of persons............................ Showers Cafeteria ( )
P4 Other fixtures .........................................................................................................
----------------------------------------
Design Flow............ ........................gallons per person del- day. Total dally flow_.......' ` __.._....__......._...gallons.
1:4 Septic Tank—Liquid capacity/400.gallons Length..j..:4_v... Width Diameter................ Dept16....1.7......
Disposal Trench—No..................... Width.................... Total Length_____............... Total leaching area....................sq. f t.
Width...__._._.._._._._-, 1.,7 " M
Seepage Pit No...i .... Diameter---IV-,n& - Depth below inlet,,3... ....... Total leaching area._j _Z__sq. ft.
Z Other Distribution box ( '_ Dosing tank ( )
Percolation Test Results Performed by.-p-weA 4.. ....... .......... Date-----;2.....................I........
Test Pit No. I... .._..minutes per inch Depth of Test Pit........; Depth to ground water.._!
G% Test Pit No. 2................minutes per inch Depth of Test Pit................_... Depth to ground water........................
P4 ..................... ..R.4�. ............................ ......................................... ------------ --------
..... _ IS
0 Description of Soil P....Z .......44k...':�12....................... Z. --cam-"--, A
U ........................................................................................................................................................................................................
--------------------------------------------------------------------------------------------...........................................................................................................
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 TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Complia has,been issued by the board of health.
_93
Signed ....... .0....... ....................................... ......zip- ja
6� /0 _ate C/
ApplicationApproved By ............. ------------ ........................................................................... .......................................
Date
Application Disapproved fps the following reaso ns: -----------------------------------------------------------------------------------------------------------------------------------------
.... ............................. ........................ .........I&Y...................................---------------------------------------*-------------------------------------- -----------------6-ate-------------------
PermitNo. ..............................................................I...... Issued ...............................------------ ------------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
/V41 BOARDA&WgA6*�
.............................................. OF --------------------------------------------------------------------------------------------------
(gertifirate of Tilraylinure
THIS IS Y, TA 4ARdividual Sewage Disposal System constructed or Repaired
f �Is ...................................
-------------------------------------------------------------
by ............... ------- .......... ...... 1.taller
at -----------------_-..............................................................................:.................. -------------- -----—-------------------------------------------------------------------------------
....... .........
has been installed in accordance with the provisions of TITLE 5 of,7rl?e'-S'ta.ri gnv' in
�ronmental Code as described i
the application for Disposal Works Construction Permit No. ................................................ dated ................_.............................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE-------------------------/`/.-../.�--.__-__?_3...........:........................ Inspector ----------------------....................__..........................
THE COMMONWEALTH OF MASSACHUSETTS
�13 BOARD
_3
.......... ............I.........OF....................................I................................................ /00
No......................... FEE........................
W
11X_ wation "Trutt
Permission her�by granted............................ ...........................................................
0 - ff-------*-----------------------
to Construct ( � or ReAr (A--)-)aAe_ t4M4,RWA.wagkWposa1-i��
atNo................................................................................................................................................................................................
Street 4.
as shown on the application for Disposal Works Construction Permi at d. ----—............. .......................... ...... ... .. .......�. .............
Board of Health
DATE......... ...... .................................
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS
FIRST FLOOR SEPTIC SYSTEM PROFILE SOILS LOG &
ELEVATION So•o FIN. GRADE FIN. GRADE OVER FIN. GRADE OVER FIN. GRADE OVER PERCOLATION TEST
TOP of AT HOUSE SEPTIC TANK DIST. BOX LEACHING PIT
FOUNDATION 4w 48.0 d $.o gg.g __4 IT). 8
TEST HOLE I TEST HOLE 2
ELEVATION 4c�>.2 ",:,9,, 0" ELEV. _ �-i.� ELEV. _
fS0112
LEVELING RING TO WITHIN �
INVERT at 12" OF FINISH GRADE I,_ I/ „ 2" of 1/8" TO 1/2 TOPSOIL &
FOUNDATION o.'a � :�:; �ro:� •a WASHED PEASTONE
4-5 SUBSOIL
ELEVATION �o Z; 4�, >w�AST, C.I. OR P.V.C. TEESD IST B0 X 3/4"00 GALLON JTO
PTIC TANK o H-10 LOADING TO BE SET ON A WASHEDBASEMENT FLOOR 0 LOADING CRUSHED
ELEVATION 3., .:•: ► .- .•: • : LEVEL & STABLE I STONE m
4-N.S _ 8' BASE PRECASTT
--�
_. ( ACME DB-3 OR LEACHING PIT
APPROVED EQUAL )
TO BE SET ON A LEVEL AND STABLE BASE H -20 LOADIN ;�
( ACME ST-1000 OR ,",PP VED EQUAL ) S.
Profile not to scale
3�'ID tom° too wAT�t2
5
., 2'_0"
101-01, PERCOLATION RATE: 2 MIN./INCH
EFFECTIVE DIAMETER TESTS BY :
TO BE SET ON A LEVEL AND STABLE BASE. WITNESSED BY RISE - --Ll
Q
Urr" 0 _M �'L c� -- " ( ACME 6,00 GAL LEACH PIT OR APP'D EQUAL ) ���,Js��,r��E BOARD OF HEALTH.
-�� DATE
WATER ENCOUNTERED AT NONE
DESIGN DATA
NUMBER OF BEDROOMS 3
'D.e� G.P.D./ BEDROOM 110 G.P.D.
- r GENERAL NOTES
TOTAL DAILY FLOW 330 G.P.D.
GARBAGE DISPOSAL NQ ! _
LEACHING REQUIRED 330 -P.0. I. ELEVATIONS BASED UPON ASSUMED DATUM.
m LEACHING PROVIDED `T19 2. ELEVATIONS AND LOCATIONS SHOWN ON THIS PLAN
PIT-5 ARE NOT TO CHANGE WITHOUT WRITTEN APPROVAL
461 OF THE ENGINEER AND THE TOWN HEALTH AGENT.
SIDEWALL AREA = (2 X`rf'v- r-.,Y_3.58 x 2.T3) Z. �2. 34 3. ALL SYSTEM COMPONENTS ARE TO BE INSTALLED IN
BOTTOM AREA = C 'r"!Y. S�>2 y- 1•o) Z = 157. 0 8 ACCORDANCE WITH S.E.C. TITLE V AND LOCAL HEALTH
47 �' j ��' TOTAL PROVIDED= (382 S.F. oe rTl �. 42 6.p0 RULES AND REGULATIONS.
4. ALL PIPES ARE TO BE CAST IRON OR P.V.C. SCH. 40.
S. THE BOARD OF HEALTH AND/OR ENGINEER TO BE
NOTE: EXCAVATE TO EL. OR LOWER AS SOIL NOTIFIED WHEN SYSTEM 1S COMPLETELY INSTALLED
I 12b� �� / , / / / I �� CONDITIONS REQUIRE TO REMOVE ALL TOPSOIL, SUBSOIL, AND READY FOR INSPECTION.
CLAY OR OTHER UNSUITABLE MATERIAL BENEATH THE 6. NORTH ARROW IS NOT TO BE USED FOR SOLAR
I I N ORIENTATION.
INLET INVERT OF THE LEACHING PIT FOR A DISTANCE
• �� ,' i �� � � / OF 10' AROUND THE PIT AND BACKFILL WITH CLEAN 7. WHEN COMPONENTS ARE SET SUCH THAT THE TOP
\_f
I 2`° -` OF STRUCTURE IS GREATER THAN 4' BELOW FINISH� Lp �a.o p SAND HAVING A PERC . RATE OF 2 MIN./INCH IN PLACE.
GRADE, HEAVY-TOP OR H=20 LOAD UNITS SHALL BE
REQUIRED.
LEGEND
/ \ SGPTzc 3 l�J o
L 4�5- th
t,07 oA EXISTING SPOT ELEV. 23. 50
/ 24
' i ! ��� 80�-' ,` ry EXISTING CONTOUR
`N PROPOSED SPOT ELEV. 24. 75 REV BY DATE7-
DESCRIPTION
PROPOSED CONTOUR 261
I r k4,
_ \ ® PROPOSED SEWAGE DISPOSAL SYSTEM
N - \ TEST HOLE
% /' t \\ �� '�L. L. C�Z'� V,� 2 i \ \ ` - - tiY -; -;Jr".F•1 ice' LOT W DOS--I \1_/OO D LAI .
STor.�E�
r h;
I
k i
i t7 F_ox i —�� a s ?,
I _4-
C Tyr-) V t'oP .t2-t1 k� APPLICANT: DAFbR AA ram►. Sr��� �s
ADDRESS: Cow MOON.Jpc_K3� LQ -
FAL
i
I ! II A'5 E \ \ - DO �./ L� ENGINEER: NORMAN GROSSMAN, R.P.E.
sE� r�no�C j A 0� LA 10 MARSH VIEW ROAD
you r ncr t j i g3� �� J
ZONING DISTRICT FLOOD ZONE ELEVATION EAST FALMOUTH, MA.
�� -
� � •'' �-� � �t�' =�.�� R F 508-548-1920
m M —�`
�.; MAP SEC PCL LOT HSE
G SCALE DATE DWN. BY / CK'D BY PLAN NO.
PLAN REFERENCE: c
BARNST. CNTY. REG. L.CC• 3gCdo��' Z SITE PLAN---SCALE I" = 30� �� �?-j AS NOTED OCT'. t-T, i��3 JTH / NG H- - -2