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HomeMy WebLinkAbout0654 MARINER CIRCLE - Health 1-654*Mariner•'Circto - - - 023 058 Cotoi t -- - - - - - - c 'i Y Y -\ COMMONWEALTH OF MASSACHUSETTS = EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION Y y TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION PropertyAddress•a- W /-?/alfz e-4 �r/L ©� s Owner's Name: e Owner's Address: Date of Inspection: - -75' `- 1 C" Name of Inspector: (please print) LG!«R,r ! clSr�t _; r Company Name: Mailing Address: l• tNn�� 47.�3G� ai:� Telephone Number: CERTIFICATION STATEMENT - co rn I certify that I have personally inspected the sewage disposal system at this address and that the in rormation 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-SSici lion 15:340 of Title 5(310 CMR 15.000). The system: a/ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fail Inspector's Signature: Date: -3-0 S' The system inspector shall s m mit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of c pleting 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 l ****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. Titlo 5 IncnPrtinn Fnrm h/15/'7oon naee 1 f� Page 2 of I 1 OFFICIAL INSPECTION FORM-NOT FOR'VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL'SYSTEM INSPECTION FORM PART A I/ CERTIFICATION(continued) . Property Address: _�S r Lk Owner: Date of Inspection:Inspection Summary: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. stem Conditionally Passes: 0 or more system components as described in the"Conditional Pass"section need to be replaced or repaired.Th ystem,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or n determined(Y,N,ND)in the for the following statements.If"not determined"please explain. The septic tank is m a]and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial ' filtration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a omplying septic tank afapproved by the Board of Health. *A metal septic tank will pass in ection if it is structurally sound,not leaking and if a Certificate of Compliance . indicating that the tank is less than 0 years old is available. ND explain: Observation of sewage backup or out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settle or uneven distribution box.System will pass inspection if(with. approval of Board of Health): broken pi s)anextplaced obstruction oved distrilutioabo is leveledor,replaced ND explain: The system required pumping more than 4 times'a ye 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: Page 3 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: $ Al,� ft_1 et- /1L Owner: Date of Inspection: 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 failin o protect public health,,safety or the environment. 1. Syst in will pass unless Board of Health determines in accordance with 310 CMR 15.3030)(b)that the syste is not functioning in a manner which will protect public health,safety and the environment: _ Ces ool or privy is within 50 feet of a surface water — Cess ool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail less the Board of Health (and Public Water Supplier,if any)determines that the system is functioning a manner that protects the public health,safety and environment: _ The system has a eptic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or 'butary to a surface water supply. _, The system has a sep 'c tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**.Me od used to determine distance **This system passes if the well wa r analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compo ds indicates that the well is free from pollution.from that facility and the presence of ammonia nitrogen and 'irate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of analysis must be attached to this form. 3. Other: Page 4 of I I OFFICIAL INSPECTION FORM'-. NOT-FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.A- CERTIFICATION(continued) Property Address: el$� IA-&2 t SA c 2_ Owner: / ,v Zse Date of inspection:`-p D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No ✓Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool :/Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or logged SAS or cesspool _ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _ ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow 7>Ke-quired 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. y 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. �iy 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.compoan:ds 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 S.ppm, provided that no other-LWWre criteria are triggered.A copy of the analysis must be attached to this form.). IZ/U (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. L e Systems: To be con ' ered a large system the system must serves facility with a design slow of 10,000 gpd to 15,000 gpd. r ;r; You must indica either`des"or"no"to each of the following: (The following crit 'a apply to large systems-in addition to the criteria above) yes no the system is wt in 400 feet of a surface drinking water supply _ the system is within feet of a tributary to a surface drinking water supply the system is located in a ni en sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water suppl ell If you have answered"yes"to any question in Se ion E the system is considered a significant threat, or answered 1. "yes"in Section D above the large system has faile The owner or operator of any large system considered a significant threat under Section E or failed under Sec n D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate egional office of the Department. Page 5 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:zo pl�<'ry i h-e/L, Owner• GcJew Z�L Date of Inspection: 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 _V 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 backup? 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: Yeo 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)] i S Page 6 of I I OFFICIAL INSPECTION FORM-NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE:DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:L�!V A&'11 c� C 12 Owner• 4�e_&/ ZZ_C Date of Inspection:�l FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): ��Q Number of current residents: 4✓ W Does residence have a garbage render(yes br no): Is laundry on a separate sewage system(yes r no):,v [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no):/Yv Water meter readings,if available(last 2 years usage(gpd)): dZ✓�'� Sump pump(yes or Last date of occupancy: COMM CIAL/INDUSTRIAL Type of es blishment: Design flow aced on 310 CMR 15.203): gpd Basis of design w(seats/persons/sgft,etc): Grease trap presen es or no):— Industrial waste hold tank present(yes or no):_ Non-sanitary waste disc h ged to the Title 5 system(yes or no): Water meter readings,if av ' able: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Record Source of informatio Was system pumped as p of the inspection(yes or no):_ If yes,volume pumped: allons—How was quantity pumped determined? Reason for pumping: TYP�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): Approx' ate age of all co<W.entsde installed(if known)and source of information: rti G& Z® ram-/ Were sewage odors detected when arriving at the site(yes or no): /r/62 ) ' t Page 7 of 1 l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: BUILDING SE R(locate on site plan) Depth below grade: Materials of constructi :_cast iron 40 PVC_other(explain): Distance from private wat supply well or suction line: Comments(on condition of jo .,,venting,evidence of leakage,etc.): SEPTIC TANK:_✓ (locate on site plan) Depth below grade:�Z Material of construction:_ ncrete metal—fiberglass_polyethylene _other(explain) v If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of certificate) Dimensions:. Sludge depth:" �t2r� Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: Distance from tof of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or aff� : How were dimensions determined: G �� integrity,Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural liquid levels as related to outlet invert,evidence of le age, GREASE%construction. on site plan) Depth belo Material ooncrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of tlet tee or baffle: Distance from bottom of scum to botto of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, ' et and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): i t s r Page 8 of i l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Z'�GG�-L�i2�n,e•2 C�/�. Owner �e�v t✓ Date of Inspection: TIGHT or R R LDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below gra e: Material of cons tion: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: allons Design Flow: allons/day Alarm present(yes or no): Alarm level: Alarm working order(yes or no): Date of last pumping: Comments(condition of alarm and at switches, etc.): �-✓ DISTRIBUTION BOX: (if present must be opened)(locate on site plan)) � 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.): PUMP CHAMBE (locate on site plan) Pumps in working ord (yes or no): Alarms in working orde (yes or no): Comments(note conditio of pump chamber,condition of pumps and appurtenances,etc.):. l R s, Page 9 of l 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) P r o p e r ty A d d r e ss: i'Z(-rverL C�2 Owner: J,(&A,' 1:f—L l Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: / TYPe •' . eaching pits,number: 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,dam soil, condition of vegetation, etc.): CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and config ton: Depth—top of liquid inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater ' flow(yes or no): Comments(note condition ol 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 f 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 'r1' PART C SYSTEM INFORMATION(continued) Property Address:,&Z, ,L t,,=,z Owner: �i✓ L Date of Inspection: 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 eaters the building. ^ c : Ll v G 1 it Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:� -7 d��i/L��-Y� e-,c 2 Owner: 4�0L✓y C Date of Inspection: _pZ F—D SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground wate. S_f et 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: served site(abutting property/observation hole within 150 feet of SAS) . 4Meecked with local Board of Health-explain: C� Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established a hi h grou water elevation: r -ECG dc>6 2 -Z, i L 11 LOCATION / SEWAGE PERMIT NO• VILLAGE INSTA LL 'S NAME i ADDRESS IUILDER OR OWNER i DATE PERMIT ISSUED DATE COMPLIANCE ISSUED IJQ 'V I fi� ' 00 No.............`3. . Fim............................. s THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH a_ ................OF...... /f ........................................... Appliration for Disposal Works Tonstrur#'inn Urrmit Application is hereby made for a Permit to Construct (,N<) or Repair ( ) an Individual Sewage Disposal System at• i . . 1� ..... ... �. ...... .. •-•••••••••• --•. ............••••••......-•.........•••......_. io s or Lot No. ••• .. .. ........ :.>............... ........... ........� .. L •-........................ ner �a A ress a ....:... ._!.. ..•- ------•-------••..................................... .................................•..........................-`---................................ � Installer Address UType of Building Size Lot_._cs��f..; 1...Sq. feet Dwelling—No. of Bedrooms_____________ _ ...._._........Expansion A�c ( ) Garbage Grinder ( ) 44 Other—Type Type of Building _. Y. C—No. of persons............:.. ( ) ( )✓ �'__.____.___. Showers — Cafeteria Q' Other fixtures --_-_--•-___---_-_-•_______________ W Design Flow........ ............................gallons per person per day. Total daVy flow..........4 ..................gallons. n i WSeptic Tank—Liquid capacity.fM. gallons Length..,-y..... Width..y..�...._ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area...........___.....sq. ft. Seepage Pit No..........1......... Diameter------� ------ Depth below inlet.rZ_?_- Total leaching area ' L1.S'i� Z Other Distribution box (/ ) Dosing t ( ) _ Percolation Test Results Performed --------- Date. ,aa Test Pit No. 1................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........................ ----------- ® Description of Soil-----.C., ...... - - Ux =.... � ............. W . , -............. --------------------- . a �------ c . e -.................................3 - 1 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 iITL% 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been ' ued by th and o iealtfi. Sig ed .. ..... ..... Xate Application Approved By......... 0 --------------------•---•--• ---••--� s......_ Q.... Date Application Disapproved for the following reasons:............................................................................................................. » ........--•--------------------------••-----------•---------••---•------------------------...-----------••--•--•----•---•--••••-•---•-------•-----•-••-•-•---------•----••---••-•-•----••••-•••...._.... Date PermitNo......................................................... Issued....................................................... Date No............ .......... Fim..............::'. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .................0F.......5i�..............................t �± Appliration for Uiipostal Works Tonstrnlrtion amit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at ............ _..- -.... .. ...... o of . ...................... or Lot No. ...S�!=...... --�4 ��... .. .. ..... .. ..�...�._1�..7�_.............-- -............-......\Z,5�--- =- 4 l.a.C...r.:�--••---------.........._.........-- r Address a.-�.c*%'"t/ •--•----•-•-•--------------- ----------------..................------....-... ........ -.......... Installer Address Type of Building Size Lot..:J ,_.�`�1�'-�....Sq. feet Dwelling—No. of Bedrooms..............:... :. ..........Expansion Attic ( ) Garbage Grinder (. ) Other—Type e of Building ,�L� ,; (? p ( ) Cafeteria ( ) � yp g ..,�---------=------- -- No. of ersons----•----------------------- Showers Otherfixtures --------------------------------------------•--------..---..--•--------------•-----------_-_..--._-------------------------.----------------•--------- W Design Flow.......5.5.............................gallons per person per day. Total daily flow...........9 vi...................gallons. WSeptic Tank—Liquid capac>ty./.,�. .gallons Length._/ '.. Width.4 .X..... Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length..��............ Total leaching area..__......._........sq. ft, Seepage Pit No....__.._/--------- Diameter.......,........ Depth below inlet.x.�.._.._... Total leaching area.... :5... Z Other Distribution box (/ ) Dosing ta#�k ( ) `" Percolation Test Results Performed b ..... '"`I ?r'......_.. " '�!2�Q..?.............. Date.... .. j� a �s ............. Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.... rJ4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water---_-_--.-------.-_-___. Ix ................................ Description of Soil...... -----�.&....... - --- / r , -------------------------------••-------------------...................................................... U .--------------------••......•......��..:__ ?......._:.. ! ......f�..... ------------------•----------------------------------------------- --------•------------ 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 Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by they and o/,h'ealtthhh ,� � -;, "71 a. -------- Application Approved By......... .r �.._-- ,.... . �......................................................................---•-----••--•-•--•-• - •----•--•.................•--•••---•-••-...----------•---•-.......-------•-•••--------.......------....----------------•-------••--•-------------------••-------------------••-----••--•------•--------- Date PermitNo............................................................ Issued............................................................. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �j�''/.G,1j,_)1Q l.t_ /: ,��`' /.... OF.......:__ ........................................ ' ............ ............. Trrfifirtt#r of Tontpliana T4IS IS TO ,PyTIFf That the Individual Sewage Disposal System'constructed ( ) or Repaired ( ) ----------------- l /l /rC/j,�/h.�/ C l�f Inslier /, ;:: at 2 � t/� i c �/�GC f . vZ` has been installed in accordance with the:provisions of 5 of The State Sanitary :Code as descri ed in the application for Disposal Works Construction Permit No _ ..........4.r................. dated_.... P................. THE ISSUANCE OF THIS CERTIFICATE SHALL. NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE......G.�`... .c .�.. (� .. Inspector. -••-•---- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No......: ......... l....... .... .............................. FED.............. 1 11.5posttl rk.9 ons# r ' r it T Permission is hereby granted__...._.. ...: - - ------• -•-- ------.--- • ......... : ............................................... to Construct (. ) or Repair ( an Individual Sewage Lispos System 11 at No... f ii. . �! __...� l�h f � .,._,_.,_: street _ as shown on the application for Disposal Works Construction Pe it No....... ` 2 � �Dated.._.. . ..�:... � ..:::......:::::::--_::::� Board of Health DATE -•-----------------•-•--•-----------------------..._._... FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS e F.FL, ELEVk-.= FINISH GRADE _ <0 SK FINISH GRADE FINISH GRADE TOP OF FOUND. OVER TANK - (p4X OVER Prr = G,,,_24 ELEV. - _ 5 C \hT.!h EY HIMN BLOCK u • \ BACKFILL 3 PEASTONE ' - 4 C.I. 4° V.C. u W�EftE NEEDED DWELLING -- _ q V.C✓ Y 0 o p O O 0 0 0 1 d Z ( \ Lt Q ,• c o ° 4 . o O O o • � 3/4" TO 1-1/2" CELLAR FL00 : ' GALLON CRUSHED STONE __-. o ELEV. _ �'` REINFORCED GONC. o O 0 O o s ' \ P i a s o 0 0 O o ° LL \10 (30 e b � e o O O () o ♦ • ° ' ° ° • . ° • DIST. BOX O 0 O O o a • o O 0 O o E - �' (TO BE LEVEL a t a v a C� 0 O o a v BOTTOM OF PIT SEPTIC TANK t_ AND STABLE) % o O O O o a 4 )�� ELEV. SYSTEM PROFILE ( NOT'TO SCALE) J LEACHING PIT DESIGN CRITERIA NUMBER OF BEDROOMS ��•0 GALLONS PER DAY GARBAGE GRINDER = l�aAJ E' NO, Ac— y� 14)x�r x TOTAL DAILY FLOW = =-'� �.P.L - PiT—.., w,..,...... "" `.' LEACHING AREA PROVIDED = _5U5 690 ft La SOILS LOG tt'; r 0 ELEV. LEAF MULCt►� ... r PROPOSED SEWAGE DISPOSAL SYSTEM INSPECTED BY� PROPOSED_DWELLING . 1Jav, � 5 `1 7 � " -1 L_- MASS. DATE _ PERCOLATION RATE L NIN./INCH SCALE AS NOTED DATE I ' -66- f f_ y, QINNED BY / �Hc.c-r AJ o PcaF.� E ► U t �e-��" L7i.1 , ANC�N4Al1U,-JT!J kA i-\s S. kr NORMAN GROSSMAN P.E., R.L.S. ��I�e 5�x 0 �� ' 226 HOLLY POINT ROAD 7 E Y I%-1 6.0 ITekil' ._ �, �4 CENTERVILLE, MASS. C-)- IL off'C`