HomeMy WebLinkAbout0122 OXFORD DRIVE - Health 122 OXFORD DRY W
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Property Address:
122 Oxford Drive
Measure#12146618 Cotuit, MA 2635
9D " Vq7
�1 << 11--7
r
uof-tn o hid
CLOSET
14'0 x 19'0
Cn
01
14'2 x 24'1
Y12 G G27`4 x 30
CLOSET
P/R
4'10 x 8'
k
CLOSET
Total interior square footage on page:1348 sf Page 3 '
The interior square footage listed is living space only and is not taxable square footage
Property Address:
Rim 122 Oxford Drive
Measure#12146618 Cotuit, MA 2635.
i
� BED OM '
[66'3
0 x 11'0 0 11'61x 12'5
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'1114 x 169 r4�
T
9
BATH CLOSET ,
O 9'6 x r6 4'0 x 6'4
"
a
Y\A �
Total interior square footage on page:699 sf Page 1
• The interior square footage listed is living space only and is not taxable square footage
Property Address:
122 Oxford Drive
Measure#12146618 Cot uit, MA 2635
00
M/BATH
9'0 x 12'6 x w
PORCH
28'0 x 25'0
MASTER BEDROOM
15'6 x 12'10
BREAKFAST AREA
13'0 x 7'0
11'10 x 14'10
LIVING ROOM
15'3 x 18'6 F/P O KITCHEN
13'0x1V6
CLOSET O m
BATH �
6'10 x 11'6 cn
J
O
BEDROOM o (?) DINING ROOM
11'4 x 12'B ° 1T4 x 1218
' PORCH
29'0 x 810 '
;
;
............................... gX l
Total interior square footage on page:_1628 sf Page 2
The interim square footage listed is living space only and is not taxable square footage
Bk 30382 Pg44 #14959
03-30-2017 @ 08 : 11a
AARGi L E S
DEED RESTRICTION
$GOK �3�0� � PAGE
The undersigned hereby agrees that the following Deed Restriction shall be incorporated in to
the Deed of property located at 122 Oxford Drive,Cotuit, Barnstable County, Massachusetts.
The building and improvements presently existing and hereafter constructed in accordance
with alterations to 122 Oxford Drive,Cotuit,Barnstable County,Massachusetts,shall not contain in
excess of three(3)bedroom space(s),pursuant to Barnstable Board of Health regulations,until such
time as approval is obtained from said Boards of Health Regulations for expansion of the existing
septic system capacity.
For title to the Grantors, see deed of Paula Danforth dated June 12,.2001 and recorded with
the Barnstable District Registry of Deeds,Book 13927,Page 65.
Executed as a sealed instrument thisAay of March,2017
WILLIAM JjqfJ6GAN
M. DUGGAhl
COMMONWEALTH OF MASSACHUSETTS
Middlesex, ss.
On this o1 day of March, 2017, before me the undersigned notary public, personally appeared
William J. Duggan and Jean M. uggan, proved to me through satisfactory evidence of
identification,which were � MO—r . ,to be the person whose name is signed on
the eding or attached d6cuments,add.acawledged to me that he/she/they signed it voluntarily
forks tated purpose.
Notaiy public:
My commission expires: 'C\NE. A40i�''-
"s . 0 o
���d9��C'�M1�Q'���►�
JOHN F. MEADE, REGISTER
BARNSTABLE COUNTY REGISTRY OF DEEDS
RECEIVED & RECORDED ELECTRONICALLY
-� COMMONWEALTH OF'MASSACHUSETTS `
EXECUTIVE OFFICE OF ENVIRONMENTAL_AFFAIRS.'
E3�ARTIYIENT OF E°1�TVIRONIYINTAL PROTECTION
TITLE :� a v
OFFICIAL INSPECTION FOR_IA4=NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM '
PART A
C.ER.TIFI CATI ON
Property Address: a
V
Owner's dame: oc
Owner's Address
.Date'dfInspection: ./0,<�KrJ'
-\ p 'P m
Name-ofInspector• (please rint) -�CJx�j 1`*/ E' j
Company Name
Mailina,Address:. CO (! . '� `
'� C z : 71
Telephone Number `7 `m
CERTIFICATION STATEMENT T
1 certify.that 1 have personally inspected the sewage disposal system at this address and*that the inFormati.on7repor[ed
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 15.3�40 of Title.5(3.10 CMR 15:000). The system:
/Passes` • ,
Conditionally Passes.
Ne _ ether Evaluation by the.hocal ApprovinQ`Authority
ails -
Inspector's Signatu�=e:. =Date:..
The system inspector shall.sZhit 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 ha`s 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
DER The original should'be sent to the system owner and copies sent to.thl buyer; if applicable, and the approving
authority.
Notes and Comments '
**x*.
This report only describes.conditiatis,at the time of inspection.and under.the conditions:of use at.that .• ' ' ,
time.,This inspection does not address'hox�the system will perform in the future under the.same or different
conditions of use.
Title.5 Inspection Form 6/1572000 page 1.
Page 2 of 11 .
OFFICIAL'INS.PECTION:FORtYI-NOT FOR OLUN I'�IZ Y ASSESSMENTS .
SUBSURFACE SEWAGE:DISPOSAI, SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 6"Alr
A
Owner:.
Date of Inspection: /O 7
Inspection`Summary: Check A,B',C;D or E/ALWAYS complete..all of Section.D
A. S .stem Passes:
I have not foundany information which:indi'cates that any of the failure cnteria described in 310:CMR
15.303 or in 310 CMR 15.304 exist.Any failure criteria.not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components.as described in the,"Conditional Pass"section need to be replaced'or
repaired.The system, upon completion of the replacement or repair; as approved by the Board of Health,will pass.
Answer,yes,no or not determined(Y,N;ND)in the for the following statements. If"not determined"please
explain.
The septic:tank:is metal arid'over 2..0 years,old,, or the septic tank(whether metal or not):is structurally
unsound,exhibits substantial:irifiltration.or exfrltration or.tank failure is imminent.System will pass inspection if the
existing tank is replaced with-a.complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20.years old is available. .
ND explain:
Observation of sewage.backup or break out or high static water level in the distribution'box due to broken or..
obstructed pipes)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 isre.moved
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 isremoved .
ND explain:
P•aee of I 1
OFFICIAL INSPECTIO - ORk-,NOT FOR VOLUNTARY'ASSESSME3�'TS
SUBSURFACE SEVIAGE DISP�OSAI" SYSTFM INSPECTTON'FORM
PART.A
CERTIFI CATION,(continued)
. Property Address: 5
Owner: N
Date of Inspection: 7 r
C. Further-Evaluation is Required by_tbe 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 eiiviroriment.
1. System will pass unless Board of 1' ealth determines in accordance'with 310 CMR 15.303(1)(b) that the
system is not functioning in a manne'r,which will;pro.tect,p.ubl;ic h:ealt'h,"safety.and.the environment: .
Cesspool or privy is within 50 feet ofa'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 Viand Public.,Water.Suppl.ier, 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 SASiis within l00 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 Vithin 50 feet ofa private water supply well.
_ The system.has a septic tank'and SAS and the SAS is less than 100 feet buv50'feet or more�from a'
private water supply well".-Method used to determine.distance
**This system passes if the well water analysis;performed at aDEP,certified laboratory,for coliform
bacteria and vol'atile'organic compounds'indicates that the'well is.free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided thatno other.
failure criteria are trigGered. A copy of the analysis:must be.attached to this.form.
3. -Other:
Page 4 of. l 1
OFFICIAL;INSPECTI0N.:FORM-..NOT FOR VOLUNTARY-ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL.S.YSTE1M-Ii SPECTION.FORM
PART A
CERTIFICATION(continued)
Property.Address:
Owner: pc .
Date of Inspection:
D. System Failure.Criteria applicable to all systems:
You must indicate"yes" or"no"to each.of the-following for all inspections:
Yes No v
Backup of sewage,into.facility or system component due to.overloaded or clogged SAS or.cesspool
_ Discharge or Pondins of effluent to the.surface of the ground or s.uTface waters due to an overloaded or
clogged SAS or cesspool
Static liquid EeveI:in the distribution-box above..outlet.invertdue 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
Required pumping more.than 4'times in.the last year NOT due to clogged or obstructed pipe(s).Number
or.times pumped
Any portion of the-SAS,cesspool or privy i.s..below high ground water elevation.
Any:portion.o f 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.
V Any portion of cesspool..:or'privy is within 50 feet ofaprivate water supply well.:
Any portion of a cesspool or•privy'is.less than 1.00 feet but greater ihan.50 feet.fro.m a'private water
supply well with no acceptable.-water quality analysis,.[This system p'assesif.the,well water analysis,
performed at..a DEP certified laboratory,for,coliform.bacteria and:volatile.organic cornpounds
indicates that the.well.is free from pollution from-that.facility,and the.:presence of ammonia
nitrogen and;nitra.te'nitrogen is equal:to or less than 5 ppm,.provided that no other failure criteria
are triggered.,A..copy-of the analysis.must be attached to this form.]
NO (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in_510 CMR 15.303,tfierefore'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 1.5,000
gpd..
You must indicate either",yes" or"no"to each of the following:
(The following criteria apply to large systems.in addition to the criteria above)
yes no
i the system is within 4.00 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.y.ou 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. 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.
Page 5 of I
OFFICIAL INSPECTION FORM 'NOT FOR vOLIIIN-TART'ASSESSMENTS '
SUBSURFACE-SEWAG..E DISPOSAL.SYSTE-M INSPECTION FORM.
PART E.
CHECKLIST t'
Property Address: / Q
Owner: Oa4 �
Date of Inspection:
w
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 4
Has the system received normal flows in the previous two week period?
v 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 or 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'deterinined'based'on:
Yes- no/ v .
✓✓ 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 CIMR 15.302(3)(b)] -
v
Pa e 6 of
11.
OFFICIAL:IN$UCTION.FORM—_'NOT.FOR VOLUNTARY.ASSESSMENTS
SUBSITRFA GE SEWAGE:DISPOSAL SYSTEI`r�G INS FORM
PART.C
SYSTEM-IN.F.QRMATION
Property Address: 9
Owner:
Date,of Inspection: U 7
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):. Number of bedrooms (actual).;
DESIGN flow based on'310 CMR 15.203 (for example: 11:0 gpd x#of bedrooms):
Number.of current residents:. f
Does residence have a garbage grinder(yes or no):
Is laundry on a separate sewage system ( es or.no): [if ves separate inspection required]
Laundry system inspected( es.or no)
Seasonal use: (yes or na):A - .
Water meter readings, ifav ilable (last2 years usace:(gpd)):05/' 340 06- 000
Sump.pump (yes or no) p
Last date of occupancy::
COMMERCIAL/INDUSTRIAL
Type of.establishment:. :
Design:flow(based on 310 CMR 15.203): gpd"
Basis of-design flow(s eats/persons/sq#,etc.): „
Grease trap present(yes:orno);—
Industrial.waste holding tank present(yes or no):
Non-Sanitary-waste discharged to the.Title 5 system(yes or no):_
.Water meter readings. if'available:'
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records.
Source of information.
Was system pumped as part ofthe.inspecfion(yes or no):
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason.for umping:
TYP OF SYSTEM
eptic iank, 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)
_Tiaht tank _Attach a copyof the DEP approval
_.Other(describe):
Approximate age of all components,date installed(if known) and source of information:
Were ewage odors:detected when'.arrivina at the site(yes or no):
6
Page 7 of 17
OFFICIAL INSPECTION FORM_]VO.T FOR'VO T
. _ LUNTA.RY ASSESSMENTS
SUBSURFACE`SE'WAGE DISPOSAL• .SYSTEM-iNSPECTTON-FORM.
PART C ;
S'YSTEM.I_-tFORMA T'ION(cortinued)
Property Address: �.
Owner:Z&AUj
Date bfInspection:
BUILDING SEWER(locate on site plan ..
Depth below grade:
Materials of construction:_cast iron 40 PVC ,other(explain):
Distance•from private water supply well or suction line:
Comments (on'condition'ofjoints,venting, eVidence'ofleakage, etc.):
t
SEPTIC TANK:_ locate on site plan)
,
Depth below_grade: _
Material ofconstrucnon:. oncrete .metal '_fiberglass Polyethylene
—other(explain)
If tank is metal list age:_ .Is ag'e:confirmed by a Certificate of Compliance(yes or no)'_(attach..a copy of,
certificate)
• 'Dimensions "iwr,�7 �C(D ° �C'� _ - ".
Sludge depth: �,j► V //
Distance from top of sludge to bottom of outlet tee or baffle:.
Scum thickness: _
Distance from top of scum to fop:of outlet tee or baffle`.. Z
Distance from bottom of scup to bottom of outlet tee-or baffle: =
How were dimensions.determinedPdathion'1,QinL1et-and:
�
Comments('on pumping recomme outlet tee or baffle condition, structural integrity, liquid levels
related to outlet invert,e idence of leakage, etc.) '
GREASE TRAP- (J(locate on:site' plan)
Depth below grade
Material of construction: concrete metal—fiberglass polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom scum to.bottom of outlet tee'or baffle:
Date of last
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidencz of leakage, etc.):
Page 8 of 1.1
'OFFICIAL-INSPECTION FORM—NOT.:FOR::.VOLUN—TARP-.ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL, SYSTEM INSPECTIOP-4 EOR_tYI
PART C. .
SYSTEM-INFORMATION(continued)
Property Address:
h . 1
Own err
Date of Inspection
i
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: -allons
Design Flow: gallons/day
Alain present.(yes.or no):.
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comm entsi(condition of alarm and float switches, etc.):
DISTRIBUTION BOX: y (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 qual,.any evidence of solids carryover, any evidence of
akage intQ or ou of box, etc
PUMP CHAMBER:: - (locate on site plan):.
Pumps in working.order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber, condition of pumps and appurtenances,etc.):
- y:
Page 9 of I 1
.OFFICIAL INSPECTION FORM:=NOT.FOR'VOI_;UNTARY ASSESSMENTS
SUBSURFACE-SEV/AGE:DISPOS:AL.-SY-STElY1 INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: '
Owner ,
Date of'Inspection: O-7
SOIL.ABSORPTION SYSTEM (SAS):All (locate on site plan, excavation not required)
If SAS-not located explain why:
y.
TyP "' F '
leaching.pits,number:.
.leaching chambers,number: "
:leachinb.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 pondiriq,.damp soil;condition of vegetation,
Gt, A6 . .
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) J.
Number and configuration:
Depths—top of liquid to inlet invert: .-
Depth`of solids layer:;
Depth of scum layer: `
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow (yes or no);
Comments (note condition of oil; signs of rydraulic`failure,jeyel.ofponding, condition of vegetation, etc.):
PRIVY:A.(locate on site plan)
Materials of construction:
Dimensions:
.Depth of solids:
Comments (note condition of soil,signs of hydraulic failure,level of ponding, condition ofveQetation, etc.):. `
9
age 0
P . 1 of 11
OFFICIAL I3YSPECTIONTORM.-.NOT EORVOLU TTARY ASSESSMENTS .
SUBSURFACE SEWAGE-DISPOSAL SYSTEM IN- SPECTION FORYI.
PART C.
SYSTEMJN:FORMATION(continued)
Property Address;/
Owner „
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
benclunarks. Locate all:wells within 100 feet:Locatz.where public water supply enters the building.
i � aila� no� 3�
O
VIA
�r
l
pate I1'of I 1
OFFIC.IAL:INSPECTION FORM =SOT FOR'VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FOR.
a . PART C
.,SYSTEM-INFORMATION(continued)
Property Address: -
Owner: Gt/
bate of Inspection:
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water feet
_ , . •. III
Please.indicate (check):all methods used to determine the high ground water elevation:
Obtained from-system design plans on record If checked, date of design plan reviewed:
Observed site (abuttirig property/observation hole within 150 feet of SAS)
Checked-with local Board ofHealth-explain:
,r
Checked with.local excavators, installers-(attach documentation)
Accessed USG 'database-ekplain:
You must describe how-you established the high ground water elevation:
r
x:
j
Permit Number: Date_ :
Completed by- ��
HIGH-GROUND-WATER LEVEL COMPUTATION
Site Location: Z� oX ® CG��l Lot No.
Owner:— Address: .
ontr ctor: Address: -- J
Ca
Notes: �� p
STEP 1 Measure depth to water table
to nearest 1/10 ft. .................c.. Date
month/day/year
STEP 2 Using Water-Level:Range Zone r
and Index Well Map locate
site and determine: r
.Appropriate index well
OB Water-level range zone ........ .................... ...::........
STEP 3 Using monthly..report"Current _..
Water Resources Conditions"_ k..
determine current depth to �®
water level for index well .........
month/year
STEP 4 Using Table of Water-level;Adjustments ;
for index well (STEP 2A),'current depth
to water level-for index well.(STER3),
and water-level zone (STEP'2B)
determine.water=level adjustment ....:...
STEP 5 Estimate,de.pth to high water;_
by subtracting the water-
-level adjustment (STEP 4)
from measured depth to water
level.at"site (STEP:11 ..: ..._.......................:..... . ...::... .................:..:. ..... ............... .......: j
Figure 13.- Reproducible computation form.
15
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Town of Barnstable
OF tHE tp�
Regulatory Services
,rs,AB Thomas F. Geiler, Director
MAS&
1639 Public Health Division
prfD MA'S p
Thomas McKean,Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
This septic system inspection report was completed by a private inspector who is certified
by.the State of Massachusetts, Department of Environmental Protection.
Although the Town of Barnstable Health Division received the original/copy of this
report; this Division does not warranty the functionality of the septic system in the future
nor does this Division agree with any technical observation s and interpretations .
contained within this report.
In addition,by receiving this report the Town of Barnstable Health Division does not
automatically approve the number of bedrooms listed within this report. The actual
number of bedrooms approved at a particular property would-be listed on the"Disposal
Work Construction Permit".
If you should have any questions regarding this report,please contact the certified Septic
System Inspector who conducted the inspection.
- t
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF:ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTI.
�< RECE'VED
W ,
APR 9
2001
r TOWN OF[3ARNSTABLE
HEALTH DEPT.
TITLE 5
OFFICIAL INSPECTION FORM.,NOT:,FOR VOLUNTARY: ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: ) -
Owner's Name:
Owner's Addres .
UAIn A 0a(005- -
Date of Inspection:
Name of Inspector: (please print) C)h 't "T. 001- 0b4-
Company Name
Mailing Address- •U
r _
Telephone Number: S['?�•77/, 9G 99
CERTIFICATION STATEMENT
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 15.00.0). The system:
Passes' . .
Conditionally Passes
eds. rther Evaluation by the Local Approving Authority.
ails
Inspector's Signatur 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 coinpleting 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
t authority..
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will.perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/1.5/200.0 page 1
Page 2 of I I
g :
OFFICIAL INS PECTION,'FORM.-NOT FOR VOLUNTARY ASSESSMENTS
iv a _l t�r1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION:(continued)
Property Address' �!�
-` - Owner.: U
Date of pection: �La/Di
Inspection Summary: Check. A,B,C,D or*,E/ALWAYS complete all of Section D
A. System Passes:
JI have not found any information which indicatesthat any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B. System-Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired.The system,upon completion of the replacement or repair; as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please
explain.
The septic'tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound,exhibits`substantial itifiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as'approved by the Board of Health.
*A metal septic tank will pass inspection.if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old.is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed.pipe(s)'or-due to a broken;settled or uneven distribution box.'System wilbpass inspection if(with`
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
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:
2
Page 3 of 11 .X
OFFICIAL INSPECTION FORMj- NOT FOR VOLUNTARY'ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A ,
CERTIFICATION(continued)
Property Address: / .) '.
f�9AT.
Owner:
Date of spection:
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 3.10..CMR 15.303(1)(b).that the
system is not:functioning in a manner which.will protect public health,safety an' d'the environment:.
Cesspool or privy is within 50 feet of a surface water ;
_ Cesspool or privy is within 50 feet of a bordering vegetated wetlan-d-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 ySAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
_ The system has aseptic tank and SAS and the SAS is within a Zone'l 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.. _ t1
_ The system has a septic tank and SAS and the SAS is less than 100,feet but 50 feet or more from a
private water supply well".Method used to determine.distance.
"This system passes if the well water analysis,performed at a DEP certified laboratory;for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen--and nitrate nitrogen is equal to or,less than 5 ppm,provided"that.no other
failure criteria are triggered.A•copy,of the analysis must be attached to this form.
3. Other: `
------------
. 3
Page 4 of'11
OFFICIAL.INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM*
PART A
CERTIFICATION(continued)
Property Address:
NOA
Owners --
Date of pection:_` 0
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to:each of the following for All inspections:
Yes N
Backup of sewage into facility or system eomponent.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 rnvert or available volume is less than %z day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number "
J 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
PP1 water supply.
. ,
Any portion of a cesspool'or privy is within a Zone l of public well.
Any portion of a cesspool or privy is within 50.feet of a private water supply well.
Any portion of a-cesspool orprivy is less than 100 feet but greater than 50 feet from a private water
supply well-with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen.is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy-ofthe analysis must be attached to this form.]
a (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 faihrre.
E. Large Systems:
To be considered aJarge'system the system mustserve"`a facility.with a-design how of 10,000 gpd to.15,000
..gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
the system is within 400 feet of a surface drinking water supply
_ the system is within 200 feet of a tributary to a surface drinking water supply
_ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered
"yes"in Section D above the large system has failed.The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304..The system owner should contact the appropriate regional office of the Department.
'4
Page 5 of 11
OFFICIAL INSPECTION FORM—.'NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
-PART B
CHECKLIST.
Property Address: J
cll ,
Date o spection: q4) /1)/
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._
i/ 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 breakout? ;
_ Were all system components,excluding the SAS, located on site
Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of..liquid,depth.of sludge and depth.of scum?
_ Was the facility owner(and occupants if different from owner)provided with information on.the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has been determined based on:
Yes no
V/ _ Existing information. For example,a plan.at the Board of Health.
_✓_ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [310 CMR 15:302(3)(b)]:
5
Page 6 of l l s.
f
OFFICIAL INSPECTIONI`FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL"SYSTEM INSPECTION` ORM
PART C
SYSTEMINFORMATION
Property Address: Q
Owner:
Date of. pection: yia in
FLOW CONDITIONS
RESIDENTIAL V�
Number of bedrooms''(design): 13 Number of bedrooms;(actual):
DESIGN flow based on 310 CMR 15.103(for example: 11.0 gpd x#of bedrooms): 33O
Number of current residents: _
Does residence have.a garbage grinder(yes or no):
Is laundry on a separate sewage`system(yes or no) [if yes separate inspection required]
Laundry system inspected(yes or no)-
Seasonal use: (yes or no):.
Water meter readings, if available(last 2 years usage(gpd)):
Sump pump(yes or no
Last date of occupanc d /Zd2(/YtGt'
COMMERCIAL/INDUSTRIAL_/,X -
Type of establishment: ..
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons%sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no):_ -
Non-sanitary waste discharged to the Title 5 system (yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: ;
Was system pumped as Pak of the inspection.(yes or 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 4.Attach a copy 4of the DEP approval
Other-(describe):
Approximate age of all co .ponents,date instal d(if known)and source of information:
i 9
Were sewage odors detected when arriving at the site(yes or no): �-
6
Page 7 of 1]
OFFICIAL INSPECTION FORM—.NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM t
PART C .
SYSTEM INFORMATION(continued)
Property Address: /20
Owner:. `.
Date of spection: O
BUILDING SEWER(locate.on site plan) /
Depth.below grade: . A
Materials of construction: cast iron "40 PVC_other(explain): ,
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: ✓locate on site plan)
Depth below grade: h,,
Material of construction:concrete metal fiberglass_polyethylene ,
—other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):-(attach a.copy of
certificate)
Dimensions:/0-6 ` p' X 5
Sludge depth:(Q '/
Distance from top of sludge to bottom of outlet-tee or baffle:
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: f�
How were dimensions determinedik�� q&CA& a
Comments(on pumping recommeddationi, inlet and outlet tee or baffle condition, structural integrity, liquid levels,
as related to outlet invert,evidence of leakage, tc.):
Q, /Skme, 62a
i
GREASE TRAI( locate on.site plan)
Depth below grade:
Material of construction:_concrete metal_fiberglass_polyethylene_other
(explain):
Dimensions:
,Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping: 3
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levelsR< <
as related to outlet invert, evidence of leakage,'etc.):
7
Page 8 of 1 l
OFFICIAL=INSPECTION FORM-NOT FOR VOLUNTARY,•ASSESSMENTS
`SUBSURFACE SEWAGE DISPOSAL 3SYSTEM INSPECTION FORM
r
PART C
SYSTEM INFOlikkTION(continued)
Property Address: 100 _C �
?4
Owner:. /I'iti C rJ�IJ�
Date of spy VA-1/0�
TIGHT or HOLDING TANK:/Z (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: -concrete metal fiberglass polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of iasrpumping:
Comments(condition of alarm and-.float switches, etc.):
DISTRIBUTIhON 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.):
- n
PUMP CHAMBE (locate on`site plan)
Pumps in working order:(yes or no): ;,..
Alarms in working order(yes or no)!,
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
lq
Page 9 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE.SEWAGE DISPOSAL:SYSTEM INSPECTION FORM
PART C+,
SYSTEM.INFORMATION(continued)
Property Address: JJQ �1 (jti0.
Kl
Owner:
Date o spection Cz /p
SOIL ABSORPTION SYSTEM (SAS):. v`(locate on site plan,excavation not required)
If SAS not located explain why:
,hype
reaching.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;damp soil;condition of vegetation, '
�( f al zieozz
CESSPOOLS/7-&—(cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no): `
Comments(note condition of soil,signs of hydraulic failure,.level of ponding,condition of vegetation,etc.):
PRI122% pcate:on site plan)
Materials of construction: '
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
Page 10.of 11
OFFICIAL INSPECTION FORM NOT.FOR.VOLUNTARY'ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM
PART C
:SYSTEM INFORMATION '(continued)
Property Address: lag
Owner: JC_
:Date of I pection:
SKET01OF 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.
i
10
Page l l of I 1
' d
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM-INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: ~
Owner: r f
Date of 1 pection: �jo?
SITE EXAM. `
Slope
Surface water _
Check.cellar.
Shallow wells -
Estimated depth to ground water feet
Please indicate(check).all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked, date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked.with local Board of Health-explain:
Checked with local excavators, installers-(attach documentation)
Accessed USGS database=explain:
You must describe how you established the high ground water elevation:
11
OF BARNSTABLE
LOCATION L.� � 7 Ox r g SEWAGE # /0" ` ?
VIk- GE ASSESSOR'S MAP LOT
INSTALLER'S NAME &°PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) ';12,'-f (size) /0
NO. OF BEDROOMS 3 � PRIVATE WELL OR PUBLIC WATER 12W/e c ,
BUILDER OR OWNER
k
DATE PERMIT ISSUED: 4wtt
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No .,.
`. Sa
M
c � �
�d 4
i
a 'Ov s M�
yY
No.,.. ..... �D Fps. ....
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
-.................11� .............OF.............Barnstable-------------------..........---•---•----•---..._.
ApptirFation for 11hipao al Workii Tayaa uurtion rumit
Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal
stem at: _
waa'._.S? s� iY.�........ ..... Lot
47--------....--- a- -----••---------------....----
Location-Address or Lot No.
_$_Beckwith Street. 01776 ......
Q er Address —_
a -----NIA-----------•--- .....ta. ..e'-••.......................................... ..-•••---..._._..__...----..._.._...••---•----.....-----••-------•••--•------._.._.._....----•--- 3
U Type of Building Installer Size Address
Lot_2Q.9QQ............Sq. feet
Dwelling—No. of Bedrooms___________________3......................Expansion Attic ( ) Garbage Grinder (Nc))
aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
dOther fixtures --------------------•--.--_...---•-••----•--•---•------•--•••-••-•-•......•=-•--•-•---------•---•--•••-------••-•--=•--•-------•-•-•••-•-•-•--•----•-
W Design Flow________________1�Q_-____-� �ca----gallons per person per day. Total daily flow_-.-.___._____330_-______•______--•_____gallons.
R: Septic Tank—Liquid capacitv:�fl@ftallons. Length__8 6"._._ Width---5�_4��__- Diameter________________ Depth__4'0"
Disposal Trench—Nor____________________ Width.................... Total Length..... Total leaching area....................sq. ft.
1 Seepage Pit No.........1---------- Diameter._..- tV. Depth below inlet.... Total leaching area__Z54.q? sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by---Baxter:..&•-Nye ••Inc.•-----------------------•.•. Date._1/25/85 -
a Test Pit No. 1----------------minutes per inch Depth of Test Pit _.12�_.-_____ Depth to ground water NoI12
(i Test Pit No. 2.........2....minutes per inch Depth of Test Pit...... 2�________ Depth to ground water---None-----------
•-• ...
0 Description of Soil...........Clean_medi�n•sand
x P� Iyjgs
--••--•--•------------•-----•-----•-------------•--------------•----•---•-------...._-•----•--•-
U Nature of Repairs or Alterations—Answer when applicable--------------------------------------------------------- - -H_ fti 1PEX..
Agreement: r
The undersigned agrees to install the afor edescribed Individual Sewage Disposal Sys
the provisions of TL 1'T1 ;of the State Sanitary Code— The undersigned further agrees not to p ��s in
operation until a Certificate of Compliance has bee •ssu d by the board of h lth.
�_i�F a-._ J -Signed_?`---- -_....- .............
. ..
to
Application Approved BY-------'------------------------------------------------ ----------- -------------------------- -._���_�'-�---��____�'�__"•---
Date
Application Disapproved for the following reasons______________________ •...---•-••----•-•--•-•--•-------•-----------•--------•--..•. ••--•-•••-•--
-------------•-----------------------------------•-------•---•--___------_____---------------
•--------------------
•---------------------------------------------------------------------
Date
PermitNo.. ................... Issued_.......................................................�J
Date
No. ....... ....... Ficim
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
................'M --- --......OF............
Appliratinn for BispAiial Works Tonstrnrtinn Frrmit
Application is hereby made for a Permit to Construct (X ) or Repair ( ) an Individual Sewage Disposal
System at: -
Oxford Drive L t 47
.....--•..............................•......_...........-----------------------------........-•-- ----...-----•---•--•--..._._.......--•-------------.------•-------------•------...----•---....•.
Location-Address or Lot No.
-__.J� I fox'G�t 8 with Skxeet. .ftlb ryr__ .01776
N/A Owner Address
W
Installer Address
QType of Building Size Lot? _(1QR-------------Sq. feet
Dwelling—No. of Bedrooms..................a.......................Expansion Attic ( ) Garbage Grinder F(40 )
'4 Other—T e of Building No. of persons............................ Showers — Cafeteria
Q' Other fixtures ............................
W Design Flow............... 14......... ?jg._gallons per person per day. Total daily flow............33 ..................._....gallons.
R: Septic Tank—Liquid capacitym t- .gallons Length..�.... ..... Width.T 4"..... Diameter________________ Depth 4 o_.........
Disposal Trench—NO..................... Width-............_..._.. Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No-------1........... Diameter____��.__........ Depth below inlet.1'.0.......... Total leaching area25L-N...sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
~" Percolation Test Results Performed by. ex-.&.Tqm..... .......................•......._ Date 05/$�......................
a 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.... 2........... Depth to ground water.NE?............
P4 ------•----•---------- ----••......••... ............-•---........-•----•-----•---•--------•-•-•----------•--•-•----•. ------------------
0 Description of Soil Clee1T1 Ced3.i..t1 S`� �j�41 FO p . ............
v •--•- •--- ••. -- •-----•--•--•-•-•--••-•---•-------••---------------------------------•••.....-------•---•---------•-•----•-•------••------- ................ � ---------
� ------- -- o ff���,fdEdll r"'
U Nature of Repairs or Alterations—Answer when applicable--------------------------------------•-------. s�_ .. ..._..
--------------------------------------------------------------------------------------------'.-•--••------------------------------......------------•-_... --- --- - -- -- ------
Agreement: STEk�� `�%
The undersigned agrees to install the aforedescribed Individual Sewage Disposa with
the provisions of TITLE j of the State Sanitary Code—The undersigned further agrees not 'q ystem in
operation until a Certificate of Compliance has bee • su d by the board of heal .
.--• .Signed .
-------••------- ................................Ql/
1:1
Application Approved - ,Dat 7
PP PP Y •......................• ..----- ..................._..--.... .fir-�. ;
. Date �
Application Disapproved for the following reasons:-------•--------------•--------•----•-------------------.....---------•-•......----•------- -•-•••......-•----
----------•----------------•-•----•-•----•--•---......------------------------------------.....-----------------••----•-••••-••-•---••--•---•-----•------••----•-------••••••••---------•--•-•-......•.
Date
Permit NoR �
---- --•-. ...... ...... Issued..
Date j
THE COMMONWEALTH OF MASSACHUSETTS
i�
BOARD OF HEALTH
'-...........................
Tnrtifiratr of Tomplianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by....................................................................................................................................................................................................
.�� V D nstaller _ r_,..a...e
at-••-----------------••-- '----------•--�-•• ��"� -- �.. ------Q-��---/....--------------•--------------••-----------------------
has been installed in accordance with the provisions of T "IE j of The State Sanitary Code as described in the
application for Disposal Works Construction Permit \o...� ..... dated_/,,.-' r+_'T ..........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE
SYSTEM WILL FUNCTION SATISFACTORY.
�� f
DATE...........�...../. ' / .............................. Inspector...... ... .._.. .........................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF
OF. HEALTH
�^
.. 07. ...`!.W el..............o F...`'............'�!�--� .%.... �/��................
o!'N ..... ._ 7
F EEeA 0i //yyY.. .
Dispolial Works T5nnotrnrtinn rrmit
Permissionis hereby granted..............................................................................................................................................
to Constrict or Repair ( ) an ndividua,-1 Se * ge.Disposal System �,,,,,
----------
Si:eet
as shown on the application for Disposal Works Construction Permit Np 0;_ �Dated���'_�_` ,..........
.................................... .. . _ .._. _......__..__...._..._...._......_
DATE--- r 1 .. .��............................................... G13e3aQ0 2
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS
FINISHED FLOOR = TYPICAL SYSTEM PROFILE FINISH GRADE OVER PIT = 5 0.2 0 -'
FINISH GRADE = 51.25 NOT TO SCALE BRICK B MORTAR COURSES AS REQU/RED TO BRING
I FDN TOP .52. 00 '', COVER TO GRADE (OVER 2000 G.P.D.) W ��
`. ,: FINISH GRADE OVER TANK = 50. 92 - 24 C.I. MANHOLE COVER Q FRAME-OVER 2000 G.P.D.
.r 8„ �6 R
PVC. OR t• p p • ® � ,. • 2� ��°
�-C. 1. TEES • • • . • 1 • . . 0 e of ° .
BSMr
FLOOR 1,000 GAL. • 1 . • • 1 / • F _.__
REINFORCED DISTRIBUTION BOX a age o'
f CONCRETE INSTALLED TO BE L L EO ON 4 • • ' '. • • • • .• • 1 ' ��� 0�E
I P
11
FOOTING n' % ' .- '"• co
:: .e„ A LEVEL STABLE BASE - . . 1 • • • • • • . • 6�P��5
1 • • ,• • 0 0 • • • 1 1 LOT 41 LOT 40
SEPTIC TANK _ 3 OUTLETS REQUIRED15000,
' 1 1 1 1 • • ,
TO BE INSTALLED ON A (OUTLET PIPES TO BE LEVEL FOR • • 6' • • • • . 'o-
LEVEL STABLE BASE FIRST 2 FEET) 1 • , 1 , , .
LEACHING P/T
GENERAL NOTES l NUMBER REQUIRED S 310 53' 20"W
/. ALL SYSTEM COMPONENTS SHALL BE INSTALLED IN ACCORDANCE WITH BOTTOM PIT 40.70 125.00' -
TITLE Q OF THE STATE SANITARY CODE DATED ✓ULY /, /977 Q ANY LOCAL
RUL ES APPL ICABL E. _ -
2. ANY CHANGE TO THIS PLAN MUST BE APPROVED IN WRITING l DESIGNED SYSTEM CONSISTS OF ONE 6')( 8'
BY JOHN K. HOL MGREN PE. LEACHING PITS SURROUNDED BY 0 N F. i
- FOOT OF 314" - /I/2" WASHED
3. WHEN CONSTRUCT/ON /S COMPLETED, PR/OR TO BACKF/LL/NG, NOTIFY THE STONE CAPPED BY 2" PEASTONE LOT 4 7 3
ENGINEER B BOARD OF HEALTH FOR INSPECT/ON. W
4. FOUNDATION ELEVATION MUST BE CHECKED WHEN COMPLETED. LOT 46 - I/ ZO�DOO S.F. o
5. THESE ELEVATIONS MUST NOT BE CHANGED W/THOUT WRITTEN APPROVAL BY ✓OHN K. HOLMGREN PE. - 0 1 1 o cD LOT 48
cD o 00
6. ALL SANITARY DISPOSAL SYSTEM PIPING TO BE 4" PVC. o 0 It 51.25 K `
' `
7. CONFIRM 4 FEET OF DRY MATERIAL B1LOW ELEV. 40. 70 WHEN SYSTEM IS INSTALLED s\\ � - `� \ 36 -N 53 - 1� \ Z
\ N 30 • N�HOUSSE
\40' �2
DESIGN SCHEDULE ELEVATION sZ,, ___ ,j 51.25 o Taannkc o 0
3
_. o �/_ o TPI
3i `R , �� Project Benchmark Front
TOP OF FOUNDATION 52 . 00 CALCULATIONS -'d " D-Bax Pit FINISHED BASEMENT FLOOR NIA TP2 �E lever=�50oao (Assumed)
LEACHING AREA REQUIRED: IR FND 2500'- _ ; IR FND
FINISHED GA PA GE FL 0 OR NIA 777 -7
3 Bedrooms of 110 GPD/BR = 3 30 GPD -
- -
' SEWER INVERT AT FOUNDATION 4 9. 6 2 _ - - -
50 % for Disposal= NIA GPD
SEWER'INVERT INTO SEPTIC TANK 49. 42 Exist. Water Service
SEWER INVERT OUT OF SEPTIC TANK 4 9. 17 TOTAL = 553 GPD O X FORD
SEVVIER INVERT INTO DIST. BOX 49.07 PERC RATE 2 MIN./INCH ( PER. ao.HJ D R 10/ E
BOT TOM'AREA = 50.26 S F, x 1.00 = 50.26 GPD
SEWER .INVERT OUT OF DIST. BOX 4 8. 90 SIDEWAL L AREA = 201.06 S F. x 2.50 = 502.65 GPD
SEWER INVERT AT LEACHING PIT 48. 70 LEACHING AREA = 251. 32 SF w/Copocity of 553 GPD
'WATER TABLE 36. 7
SOIL LOGS SCALE - 1 "=4 '
DATE AUG. 7, 1990 ENGINEER STEPHEN A. HAAs BOARD OF,,•HEA LTH AGENT PETER
TEST PIT I TEST PIT 2 TEST PIT 3 TEST PIT 4 . . TEST PIT 5
ZONING DISTRICT : RESIDENTIAL - F •` -� �� ccrw_,
EL EV.=48.7 E L EV =48.9 MINIMUM ZONING REQUIREMENTS,'
FRONT 30 `' ,1;.
GE.:;..._. .
TOP TOP SIDE 15 V.. j,,
a a REAR 15'
SUBSOIL SUBSOIL �(\
3' 3'
Med.- I CERTIFY THAT THE SEWAGE D/SPO S YSTEM
So
5o d Perc SHOWN HAS BEEN DESIGNED IN ACCO ANCE WITH A F
0 08"I"i"' H
r N1ed.- TIYLE 5 OF THE STATE ENVIRONMENTAL CODE J A N4 IF U I Vf�
No H2O Encountered AND THE RULES a REGULATIONS OF THE LOCAL
BOARD OF HEALTH.
Coarse ON SI TE SA NI TARY DISPOSAL SYSTEM
_
Sand L 0 4"T 0 X F 0 D D RZ. I
} � DESIGNED BY :
LEGEND J. K . H . 0 UP" A It 10' l 03L KPA
12 EXISTING CONTOURS la!--- �- DRAWN BY: , CHECKED BY: J.K. HObYGREN 8 ASSOCIATES INC
H2O Encountered PROPOSED CONTOURS l0/ T.M.E. J. K.H.
EXISTING ELEVATIONS I0/xOO SCALE: DRAWING NO. REGISTERED PROFESSIONAL
' PROPOSED ELEVATIONS loi I "= 40' ENGINEERS
Aljo BELI�9ONT sr
THE ,
THE DESIGNED SYSTEM /S BASED UPON THE SOIL DATA SHOWN ABOVE. SHOULD SITE CONDITIONS BE FOUND DIFFERENT . TEST PIT DATE` BROCKTON, MASS. 02401
AT THEY'TIME OF CONSTRUCTION J.K. HOLMGREN a ASSOCIATES INC. SHOULD .BE CONSULTED PRIOR TO CONSTRUCTION. 10-31-19SO '
90 - 618 - • 1