HomeMy WebLinkAbout0039 MELISSA LANE - Health 39 Melissa Lane --
Cotuit
A = 010 010003
,
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 39 Melissa Lane
Property Address
Linda Reilly
Owner Owner's Name
information is required for Cotuit Ma. 02635 4' 12/10/2009
*
every page. City/Town State Zip Code spate of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important: A. General Information
When filling out
forms on the
computer,use 1. Inspector:
only the tab key
to move your Robert Paolini
cursor-do not Name of Inspector
use the return
key. Capewide Enterprises,LLC.
Company Name
P.O.Box 763
Company Address
Centerville Ma. 02632
01 City/Town State Zip Code
(508)428-4028 S14454
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. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
pt o
❑ Needs Further Evaluation by the Local Approving Authority
W12/10/2009 '
Ins or's Si a`tt a Date
The system inspector shall submit a copy of this inspection report to the Appro ing Authorrity(Board
of Health or DEP)within 30 days of completing this inspection. If the system is. shared�syster�;gr
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall suRit 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.
t5ins•09108 Title 5 Official Inspection Form:Subsurface ewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 39 Melissa Lane
Property Address
Linda Reilly
Owner Owner's Name
information is required for Cotuit Ma. 02635 12/10/2009
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:
® 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 septic system is in proper working order at the present time.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old,is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Y
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 39 Melissa Lane
Property Address
Linda Reilly
Owner Owner's Name
information is required for Cotuit Ma. 02635 12/10/2009
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 39 Melissa Lane
Property Address
Linda Reilly
Owner Owner's Name
information is required for Cotuit Ma. 02635 12/10/2009
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory,for 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
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1h day flow
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
39 Melissa Lane
Property Address
Linda Reilly
Owner Owner's Name
information is required for Cotuit Ma. 02635 12/10/2009
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply
well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA)or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 5 of 17
I Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 39 Melissa Lane
Property Address
Linda Reilly
Owner Owner's Name
information is required for Cotuit Ma. 02635 12/10/2009
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?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (if they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ 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(5)]
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
t5ins•09/08 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
39 Melissa Lane
Property Address
Linda Reilly
Owner Owner's Name
information is required for Cotuit Ma. 02635 12/10/2009
every page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
The septic system consists of a 1500 gallon tank,D-Box and four infiltrators.
Number of current residents: 2
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
Seasonaluse? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d 2008:179,000
9 ( Y 9 (gpd)): 2009:92,000
Detail:
2008:490 gpd 2009:252gpd.
Sump pump? ❑ Yes ® No
Last date of occupancy: Date 0/2009
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
39 Melissa Lane
Property Address
Linda Reilly
Owner Owner's Name
information is required for Cotuit Ma. 02635 12/10/2009
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: Capewide Enterprises,LLC.
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: 1500
gallons
How was quantity pumped determined? Measured
Reason for pumping: Maintenance
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
39 Melissa Lane
Property Address
Linda Reilly
Owner Owner's Name
information is required for Cotuit Ma. 02635 12/10/2009
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
2002
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
4, _
Depth below grade: feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line. 10'+
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Joints appear tight.No evidence of Ieakage.System vented through the house vents.
Septic Tank(locate on site plan):
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) j
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1500
Sludge depth:
0"
t5ins•09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
39 Melissa Lane
Property Address
Linda Reilly
Owner Owner's Name
information is required for Cotuit Ma. 02635 12/10/2009
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle NA
Scum thickness
0"
Distance from top of scum to top of outlet tee or baffle NA
Distance from bottom of scum to bottom of outlet tee or baffle NA
How were dimensions determined? Tank pumped at inspection.
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pump septic tank every two years.lnlet and outlet tees are in place.No evidence of leakage.Tank
appears structurally sound.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�GM 39 Melissa Lane
Property Address
Linda Reilly
Owner Owner's Name
information is required for Cotuit Ma. 02635 12/10/2009
every page. City/Town State Zip Code .Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins-09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 39 Melissa Lane
Property Address
Linda Reilly
Owner Owner's Name
information is required for Cotuit Ma. 02635 12/10/2009
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert No
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.):
Box is Ievel.Box has one outlet lateral.No evidence of solids carryover.No evidence of leakage.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
39 Melissa Lane
Property Address
Linda Reilly
Owner Owner's Name
information is required for Cotuit Ma. 02635 12/10/2009
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 4-Infiltrators
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
I
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Sandy dry soil.No signs of hydraulic failure.No ponding or damp soil.
I
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
—Depth to of liquid to inlet invert
P P q
Depth of solids Layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•09/08 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 39 Melissa Lane
Property Address
Linda Reilly
Owner Owner's Name
information is required for Cotuit Ma. 02635 12/10/2009
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
39 Melissa Lane
Property Address
Linda Reilly
Owner Owner's Name
information is required for Cotuit Ma. 02635 12/10/2009
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system,-including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
❑ hand-sketch in the area below
❑ drawing attached separately
J�
I 15 4,5 I
18
311 3 5
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
i
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 39 Melissa Lane
Property Address
Linda Reilly
Owner Owner's Name
information is required for Cotuit Ma. 02635 12/10/2009
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 high ground water: Bottom of leaching 26'
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: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
As-Built
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
USED:USGS Observation Well Data.USE D:Technical Bulletin 92-0001 plate#2 annual ranges of
groundwater elevations.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
i Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,.' 39 Melissa Lane
Property Address
Linda Reilly
Owner Owner's Name
information is Cotuit Ma. 02635 12/10/2009
required for
every page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary:A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
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LEACHING FACILITY: (type') jl-,atPS (size) 3-1 X
NO. OF BEDROOMS 3
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PERMITDATE: �O / COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility (If any wetlands exist
within 300 feet of leaching facility) Feet
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LEACHING FACILITY: (type) 4gat-af6yS (size)
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PERMITDATE: I;� �o�/ COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted� Groundwater Table to the Bottom of Leaching Facility A'Lit .4 Feet
• Private Water Supply Well and Leaching Facility (If any wells exist
on site or within4200 feet of leaching facility) �a rs v Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 3100 feet of leaching facility) Feet
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BOARD OF HEALTH
f OW nl OF ,a&d S 71Mk;
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION
Application for a Permit to Construct (%.44,epair ( ) Upgrade ( ) Abandon ( ) - omplete System ❑Individual Components
Location Owner's Name
v a3
Map/Parcel# C1 Address
Lot# Tele hone#
taller's Name Ins signer's Name
Address r
Telephone# Telephone#
Type of Building: aEqu f am L Lot Size -0%1_Sq.feet
Dwelling—No.of Bedrooms Garbage Grinder ( )
Other—Type of Building No.of persons Showers ( ), Cafeteria ( )
Other fixtures
Design Flow(min.required)&�30 gpd Calculated design flow gpd Design flow provided gpd
Plan: Date _ Number of sheets Revision PAte
Title &S l—
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS !!ff
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
TITLE 5 and further agrees not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
4 Si neSi ned GIM�J Date O I�
E7 C�i,,- S,cu"ac, V--tp�-k I La// 0
FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
i,!�:, _,,,a,_.,. J/ y rr y �..' r"1��, Ir ,(•. f f. R Fi '°T .. r l e.
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No. �/��p•,�II yifZ+G5 }�. w4Q^.. ! 4` ; ?""11 1-
WI THE COMMONWEALTH OF M'ASSACHUSETTS ....: E
3 ,. BOARD .OF H.EALT.H ;. ZM_
— OF 46A1f61W194&
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION P
Application for a Permit to Construct (-,)''Repair.( ) Upgrade (, ) Abandon ( ) - omplete System El Individual Components
Location nerSName."T.`
Map/Parcel# Address
V \TeJe qne v#�in \
^� Installer's Name �I ! si neF s Na c i4,
S 01 --C�7 AL.e:s
Telephone# Telephone#
sir . {
Type of Building: �D � LSD t'1 Lot Size ;1t[1 f Sq.feet
Dwelling—No.of Bedrooms `- Garbage Grinder ( )
Other—Type of Building ... No.of persons Showers ( > Cafeteria ( )
Other fixtures
Design Flow(min.required)060 gpd Calculated design flow gpd Design flow provided 38?-'gpd
Plan:-Pate JJ t Number of sheet3 Revision Plate
Titlel�Usl-
- Description of Soil(s)'_
5 Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
;. •-arseir.;
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance`with the provisions of
TITLE 5 and rther agrees of yolace the system in operation until a Certificate of Compliance has been issued by the Board of Health. i
Si ned MACIMt. Date.. � �� ,`�,Q /
lu
FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 r
t; f
_-_ _-__,. -- _� �-�..,.Q ..,_- __r..,.--_.-_ --.,_-_ ___
NO.1(20D' �/ ��} THE COMMONWEALTH OF MASSACHUSETTS �wp FEE _ b
^. F` RV 7�)Q_4 BOARD OF HEALTH
CERTIFICATE OF COMPLIANCE
'Description of Work: ❑ Individual Component(s) Complete ystem
_:The undersigned hereby certify that the Sewage Disposal System;Constructed( ,Repaired( ),Upgraded( ),Abandoned( )
by:
is
at -
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built
plans relating to application No. ��'al dated _'_JAP10 j Approved Design Flow S3 0 (gpd)
'l"', Installer Q"� v aD
Designer: �-(M \LOA A Inspector \Q�ate .
- i
The issuance of this certificate shall not be construed as a guarantee that the system will function as designed.
FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96
1
No.RCb/_)y3 THE COMMONWEALTH OF MASSACHUSETTS FEE
1C BOARD OF HEALTH
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to Construct ) Repair ( ) Upgrade ( ) Abandon ( ) an individual sewage
h. disposal system at RX l<1 as described
in the application for Disposal System Construction Permit No. 64001 dated��(�
Provided: Construction shall be completed within three years of the date of this permit.All local conditions must be met.
9bIn/ d Date Board of Health UAL
FORM 2 - DSCP DEP APPROVED FORM 5/96
FORM 1255 (REV 5/96) H&W HosBs&WARREN'M PUBLISHERS- BOSTON
1
r
t
No.9Zb�—)U3 THE COMMONWEALTH OF MASSACHUSETTS FEE -
2HA1)2-11NAQZ>1-e BOARD OF HEALTH
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission istereby granted to Construct (x) Repair ( ) Upgrade ( ) Abandon ( ) an individual sewage
disposal system at _� + as described
in the application for Disposal System Construction Permit No. 9CJI_:1 CFI dated .�oI
Provided: Construction shall be completed within three years of the date of this permit.All local conditions must be met.
Date =22,? I L" II b Board of Health, [AA'A-x
FORM 2 - DSCP DEP APPROVED FORM 5/96
FORM 1255 (REV 5/96) H&W H013BS&WARRENTM PUBLISHERS- BOSTON
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P.ram.nary plans ana layout{by RC.O.are for[he use.of,tne.o customs omy Any otne. u>e.>stet ny F.oPio.tc
� AREA PLAN
•
S YS TEM PROFILE
M;
SCALE: 1 "-50 '
FINISH GRADE NOT TO SCALE
FINISH GRADE FINISH GRADE
NOTES.. `, ; C .�5 G .a OVER TANK OVER TRENCHES .
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TOP FNO
APPLICATION NUMBER P-8456
y SCH 40 PVC e
tg4.80 i OR —
" . CAST IRON TEES Sti
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1. ELEVA TIONS BASED ON ASSUMED {' � ... •�t lo4.Z(o wd•.tQ
2. TOWN WATER ON SITE
BSM'T FL „'`• t ;� r
ya 5500 GAL. EQUALIZERS Co3. p
3. FLOOD ZONE 'C' RE_ `- INFORCED
,.
N� GAS
DIST.BOX
.. .� CONCRETE ,f s•'•��:�;:..':::,•..,,.•;:;..�:.,•; '�;•.-:•SL
'4��:,.:..... .• j ,,,,,.. ...,.,•. . ;.' ........ ..,;,::. BAFFLE ;s.:%t..�..•-.�. .1. . ...=:- 's:•.'..,,•Z;•-
:. ....�.,. .,�•.:.!.�:::.•., •.;.:o.,i.• • .Y TO BE INSTALLED ON A �="• • '"•" •
LEVEL STABLE BASE
SEPTIC TANK TRENCH -LENGTH
TO BE INSTALLED ON A 32 0_0 it
NOTE.' LEVEL STABLE BASE
THIS PLAN IS A REVISION OF 5'MIN.HEIGHT
A PLAN DATED MARCH 28, s995 NOTE: � O ND T RUN HEAVY EOCJIPMENT OVER S YS TEM A6ovE OBSERVED
__.� __._..,... _,.._...._ GROUND WATER
LEACHING INFIL TPA TOP SECTION
NOT TO SCALE SOIL AND PERCOLA TION DATA
NOTE.,
FOR FINISH GRADE
A SOIL EVALUATION IS REOWRED
PRIOR TO EXCAVATION. THE SEE S YS TEM PROFILE - —
CONTRACTOR IS TO CONTACT MIN. 2" — 1/$"-1/2"
FERREIRA.ASSOCIATES TO VERIFY , ^ �� / Ur; • r /, r
rhP r rsui,,�.� ,RetC•';F'V A r�iq/ � A' A/iX'.6'�! - '°,� 5 MIN/IN.
/--
WASHED s TONE
PERC. RA TE
THE SOIL CONDITIONS ON SITE }
(12"MIN.J TAKEN BY RMHAW FEMEIRA
WITNESSED BY ED &IWY
►. •, •: DA TE MARCH 24 J&W
4"CIA PIPE 'a '• ' ' :;..,. ..
•• •• TEST PIT ELEV. 66.7
REVISED 5/15/02 SH0WIN6 ,•, �,. :. (PERC'D AT 60'I APPLI. AV.P-B4W
RELOCATED HOGCSE/6ARASE CU9VE RADIUS ARC �- NA TOPAL SOIL ••°' 4 ;; EFFECTIVE 0
RELOCATED SEPTIC 25.00 21.74 y e;i•, DEPTH + (J
3/4 -1 1/2 -.e. e . .-. .. QPSOIL-S T GlB.SOIL
WASHED STONE ..• : .o. i• . • • :� 96" _..__ ;_.._. __ __ I
EFFEC TI VE WIDTH
�r 10'-10'
EXCA VA TEL) SIDEWALL I ,
a 4•-0• 4-—0' a
NUMBER` OF TRENCHES 1
d LOT 2
I NUMBER OF INFIL TRA TORS 4 #
Ao AZ. 44 4�' 48 60 5Z � 58 �° 144•t_ _&ROLWOWATER._
20 FT'
. MIDE ORAINA6E EASEAJENT 171 S. F. SIDEI✓A L L AREA . 74 GALS/SF 126 GALS.
' NO.OF BEDROOMS 9
N 73 40'14'E ( f DISPOSAL NO
170.B4 f 346 S. F. SOT TOM AREA . 74 GAL S/SF 256 GALS./ EST. TOTAL DAIL Y EFFLUENT 39 GALS.
I f ,f F !' 1500 0
/_ SEPTIC TANK GAL.
1 1 ; ► ;� IS 517 S.F. TOTAL AREA GAL SISF 382 GAL S.
/
t Sq
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n •7n1ns ,..,
R / aEV ` = : ��,�,,F _ GENERAL NOTES
r tea'SO .......= '�� C1 . .. !
sy s e9. NOTE., 1 . ALL SYSTEM COMPONENTS SHALL BE INSTALLED IN
EXCA VA TE TO EL EV. ACCORDANCE WI TH TI TLE 5 OF THE STA TE SA NI TARY CODE
` raao`� "-� -_ 't•Op F . OR LOWER AS REQUIRED
�• �w DATED MARCH 1995 AND ANY LOCAL RULES APPL ICABL E
°
0� BAL. G� TO REMOVE ALL LOAM AND CLAY CONT4INING
LOT 3 P". c� e�� -0 - MATERIAL BENEATH THE LEACHING AREA.REPLACE 2. ANY CHANGE IN THIS PLAN MUST BE APPROVED
Baww. ` 1, eAW
`' T rTH M) - EXCA VA TED MATERIAL WITH CLEAN CLAY FREE GRAVEL B Y THE BOARD OF HEAL TH AND FERREIRA A SSOC.
MALK-O!/T r
N 43,, 561 S. F. jwrL rm7a98 MITH
U� -+'�'---cc , sraAcc ARau� MECHANICALLY COMPACTED IN PLACE 3. WHEN CONSTRUCTION IS COMPLETED, PRIOR TO BACKFILLING
� � Fj s�• x so•-so• x a.
/ , Pti? O�e�j� rsE�w+a�:L� NOTIFY BOARD OF HEAL TH FOR ,INSPECTION
SLOT 4 4. FND. EL EV V. MUS T BE CHECKED WHEN COMPLETED
REVISED 9/29/02.' 5. THESE ELEV.MUST NOT BE CHANGED WITHOUT
i , 0 L EGEND SHOW SANTUI T RIVER
THE BOARD OF HEAL TH APPROVAL
z� 6 200' SETBACK BWFER
' 6. BOARD OF HEALTH INSPECTION RECJ D WHEN EXCA VA TED
r
G0-- EXIST.GROUND EL V.
}
FINISH GROUND ELEV.'
I M ti
S _ q bad f{
175.14 „
SEWAGE DISPOSAL SYSTEM PLAN
' .8r� PIPE INVERT ELEV. ` ^
S 70 351oe�W • -^ PREPARED FOR
\ � 9
TEST PIT LO%'A TION M,46 47 :
64
. tr o o SEPTIC TANK COMPASS REALTY TRUST
fr
r� Drsrareurroa eox LOT 3 MEL ISSA LANE
LOT A
4•c.r.OR scH 40 PVC 3. BARNSTABL E — MASS.
4"BIT.FI8ER PIPE-fiIGHT ✓OINTS r r
r ..
s 4 .q "
PROPERTY LINES
;{ DESIGNED: SAP DATE:MARCH 1, 2001
rit n v:;
FERREIRA ASSOCIATES.
SETBACK DISTANCE �' '� " x.. ,x<; •; WN. SCALe AS SHOWN 131 SPRING BARS ROAD
•.:. ♦ , ,
DRA
gk
.t 0 3 3 t FALMOUTH MASS.
W 6
.' CHECKED. 6S -ORA IN NQ 030101
T SE
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NO TE: DO NO T RUN HEA V Y EQUIPMENT O VER S YS TEM ABOVE OBSERVED
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A SOIL EVALUATION IS REOUIRED FOP FINISH SPADE
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(12"MIN.l 1 TAKEN BY RICHARD FE/WIRA
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•�`,, ?a _" cs `,�o- q�'F ..._ ! _ GENERA L NO TES
NO TE.'
a9• x' I . AL L S YS TEM COMPONENTS SHAL L BE INS TA L ED IN
R ;�,\ �' �c t•00 4�~F EXCA YA TE TO ELEV• 5 .5 "OR LOWER AS REouIRED ACCORDANCE WITH TITLE 5 OF THE S TA TE SA NI TAR Y CODE
• ' yrP ge Y a' ? TO REMOVE ALL LOAM AND CLAY CONT4INING DATED MARCH 1995 AND ANY LOCAL RULES APPLICABLE
e cv LOT 3
7 MATE,4IAL ;BENEATH THE LEACHING AREA.REPLACE 2, ANY CHANGE IN THIS PLAN MUST BE APPROVED
� � y "1• � Q,� .`,'.•;. o DSST. �/' ��lT A4A�LLSfO LEAL�II/W
43° 561 • F. S9 0 eax �,P TES Mrn+ (4) EXCA VA TED MA TERIAL WI TH CL EA At, CL A Y FREE GRA VEL
N N XW.MTRATOW MYTH B Y THE BOARD OF HEA L TH AND FERREIRA A SSOC
rsoo eAc. �40 4• sraVE ALL AaocAV MECH4NICALL Y COMPACTED IN PLACE
7AWSip q(�j p' � �L x R• 3. WHEN CONSTRUCTION IS COMPL E TED, PRIOR TO BA CKFI L L ING
NO TIFY BOARD OF HEA L TH FOR INSPEC TION
` ` � .,\ a• s°� �p �Oqh� LOT a 4. FND. EL EV V. MUS T BE CHECKED WHEN COMPL ETED
`z LEGEND 5. THESE ELEV. MUST NOT BE CHANGED WITHOUT
y THE BOARD OF HEAL TH APPROVAL
+ ' z° 6. BOARD OF HEAL TH INSPECTION REG 'D WHEN EXCA VA TED
1
EXIST.GROUNE7 ELEV.
FINISH GROL41D ELEV:
:75. s4 SEWA GE DISPOSAL S YS TEM PL AN
S 70.35'04"W fo4_ PIPE INVERT ELEV. '
+ 5 TEST Pr L01,ATION
: a. PREPARED FOR
46
AZ ` 58 54
44 4b xfl p o SEPTIC TANK '
�fr
•
COMPASS REAL T Y TRUST
[3 DISTRIBUTION Box
LOT 3 MEL ISSA LANE
LOT A /
4"C.r.OR SCif 40 PVC '
BARNS TABL E -- MASS.
4*Br T.FIBER PIPE-TIGHT JOINTS
PROPERTY LINES z w 8
DESIGNED SAP DATE:MARCH J. 2001 "
FERREIRA A SSOCIA TES
' s a SETBACKDISTANCE
_..
. <.. . , _W ,. DRAWN: SCALE. W
,. tp A E As SHOWN 13.1� SPRIG BARS
,• 10 sD 3 e N ROAD
.;. FALMOUT
��
H MASS.
�. GYILCKED . W G
` MAP - SEC PCL LOT HSE
QR,4 IN NO. 090J01
,..
,
. .•. to "f:'Wl,. .. ✓'.'^w ,..: .,-,c:,+
,
p'
x,
.. .. ,..n..... ,.,..z, :..: r ,.... ....._,.. ,. ...f,. , ...:.. ., z:
AREA PL AN
SCALE.' 1
S YS T �:. . PPOFIL E
s 50 '
j,::1rNIs1-1 GRADE N07' T.0 SCALE
_ FINISH GRADE FINISH GRADE
NOTES.' G7.0 �s. f 7 OVER TANK OVER TRENCHES
TOP FND
APPL ICA TION NUMBER P-8456
SCH 40 PVC
OR '
64.B0 ►i.�. CAST 1 RON l EES S. ^
1. ELEVATIONS BASED ON ASSUMED4-• P T r: i
2. TOWN WATER ON Sr TE BSM'T FL R ? !0 4.2Ca �d .I O ' : r ` ; " '•'•.•
3. FLOOD ZONE "C ; `.i 1500 GAL. :+ EOUALIZE•RS
REINFORCED
`i• :► CYNVCRETE •{ BAFFLE GAS DIST.BOX
_.. ,... , ,• ,^ e,• • .�.��
�. .�; . , .tyy;r;.. �•...y. TO AE INSTALLED ON A I:;'::.: %.:�: i•; :•+�
LEVEL STABLE SASE
SEPt'IC TAII'�IK TRENCH LENGTH
TO BE XNSTALLED VIVA 32 -0
3 NOTE.'
jREVISION OF LEVEL STABLE BASE
THIS PLAN IS A REV
A PLAN DATED MARCH 28. 1995� V V 5`mm.HEIGHT
NOTE. DO /Vor RUN HEA Y E(.�UIPMENT O ER SYSTEM ABOVE OBSERVED
f
GROUND WA TER
c,A CHING INFIL rPA TOR SEC TI61Y
-F - NOT TO SCALE SOIL AND PE `COLA TION DATA
NO TE.,
A SOIL EVALUATION IS REQUIRED FOP FINISH GPADE
PRIOR TO EXCA VA TION. THE SEE SYSTEM PPOFIL E
CONTRACTOR IS TO CONTACT
FERREIRA ASSOCIATES TO VERIFY �� .
1L�THE SOIL CONDITIONS ON SITE �.. //� / // 'iAl/ ice/ /�� /� / WASHECTLNE PERC RATE " " MIN/IN.
02"MIN.J TAKEN BY Rlaft 1D FEMETRA
WITNESSED BY ED BARRY
:'g:`.: ;• ,. DA TE MARCH 24. 19W
4"CIA.PIPE ° too'
'•• • TEST PIT ELEV. 66.7
CU4VE RADIUS ARC �- NATURAL SOIL a�i°� f•• � � EFFECT!'VE � '�D AT 60'� APPLI. MD.P-B456
1 25.00 21.74 'y e'�•�• DEPTH 0�
' ►•'• ,'', ••�a
9 a
• TOIPSOIL-SG9SOIL
WASHED STONE ..• •• ••a���S'.'e:°.t':;:; •. �. s.. '� SSr
EFFECTIVE WIDTH A
._... _.__.. . ..... ____._____....
EXCAVATED SIDEWALI t0'—to" L_
_ MEDIUM Svl/VD _ -
NUMBEP OF TRENCHES �4
V.
LOT 2 t "
A° �2, �$ �_o �� 5� u •� NUMBER OF INFIL TRA TORS 4 k
sill
NO eR0iMWATER
DESIGN DA TA i
20 FT. HIDE DRAINAGE`EASEMENT_
' N 73.40'14•E , 171 S. F. VDENAL L AREA . 74 GAL S/SF 126 GAL S. s
NO.OF BEDROOMS
346 S. F. BOTTOM AREA . 74 GALS/SF 256 GALS.
DISPOSAL NO
EST. TOTAL DA IL Y EFFLUENT 330 GALS.
517 S. F. TOTAL AREA GALS/SF 38`2 GALS. SEPTIC TANK 1500 GAL•
m
i f / �� j �'� ,' ;` �. _✓�
00 / 1 B5' r ( sEi�allupl �Zo
no
j ; ✓s ' �sa_._ ELEV••70. __.q 1 1LqN GENERAL NOTES
'ria S C
o s NOTE.'
\ /� ��o e9 va 1 . ALL SYSTEM COMPONENTS SHALL BE INSTALLED IN
s';v?4 �51 _ J 00•49`F EXCAVATE, TO ELEV, 57 a OR LOWER AS RE@UIRED ACCORDANCE WI TH TITLE 5 OF THE STA TE SANITARY CODE
o . , ,•,.�, { �` DA TED MARCH 1995 AND ANY LOCAL RUL ES APPL ICABL E
. N \ e �� TO $EMOVE ALL LOAM AND CLAY CONT4INING
b ° '' LOT .3 `,'' �---���` MA T�'RIAL BENEA TH THE LEACHING AREA.REPLACE 2. ANY CHANGE IN THIS PL AN MUS T BE APPRO VED
GIST. �J PROPOSED LEACHIM6
• M 1 oo/�j am / �; �e rAEn�H wrTH !�� EXCA VA TED MA TERIAL WI TH CL EAN, CL A Y FREE GRA VEL BY THE BOARD OF HEALTH AND FERREIRA A SSOC. •=4
N N .43, 56.i S. F. `� ��L 4 rWZ1.VUT0RS WrH
cy 1500 SAL. • ('� - +,� ` STcwE ALL ARO(N�I' MECHANICALLY COMPACTED IN PLACE
\\ 1 G`• SEPTIC/ P 3. WHEN CONSTRUCTION IS COMPLETED, PRIOR TO BA CKFIL L ING
TAB '` �? 0•hh lSEE PHQFrLEJ NOTIFY BOARD OF HEALTH FOR INSPECTION
40 `��� \ ____ so` ' 0� roA•of �L LOT 4 4. FND. EL E V. MUS T BE CHECKED WHEN COMPL E TED
h __
Gz 5. THESE EL EV V. MUS T NO T BE CHANGED WI THOU
i ! o L EGEND THE BOARD OF HEAL TH APPROVAL t
6. BOARD OF HEAL TH INSPECTION REOJ D WHEN EXCA VA TED
c04-- EXIST.GROUND ELEV.
FINISH GROUND ELEV.
1 1 '�
i175. 14 ' Ca4•gp PIPE INVERT ELEV, a` f -SEWA GE DISPOSA L S YS TEM PL A N
PREPARED FOR
TEST PIT L OCA TION
46 4Z 52 54
44 4` '+ sb O O SEPTIC TANK COMPA SS REA L T Y TRUS T
o DISTRIBUTION BOX � LOT 3 MEL ISSA LANE
LOT A
4"C.r.OR SCH 40 PVC ��<f"f =-y BARNS TABL E -- MASS.
�++t►w. 4"BIT.FIBER PIPE-TIGHT JOINTS
._ PROPERT I LINE'S t DESIGNED: SAP DA TE:MARCH J. 2001
FERREIRA ASSOCIA TES
SETBACK DISTANCE DRAWN: J,p SCALE!AS SHOWN
10 10-3 3
131 SPRING BARS ROAD
-�� `•< ,+ +`' ' FALMOUTH — MASS.
MAP SEC PCL LOT HSE +• CHECKED 6.4 DRAWING NOV 030101
'