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HomeMy WebLinkAbout0485 POPONESSETT ROAD - Health 48S Popor.essett Road, Cotuit `019 - 004 - 001 \I r p -CIO COMMONWEALTH v COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAI DEPARTMENT OF ENVIRONMENTAL PRO ECTION ONE WINTER STREET. BOSTON, MA 02108 617-292-F500 w1LL1AM F.WELDto�yoF 8 19 �Y COXE Govemor yFq Bq9 9? Secretary ARGEO PAUL CELLUCCI (P .STRUHS Lt.Govemor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FO, ommissioner PART A CERTIFICATION r -_9 Property Address: P � �d l..o; �a Address of Owner: (k C Date of Inspection: I —icJ" (If different) Name of Inspector:' o I am a DEP a prove st m to ector pyrsuan Company Name: to.Section 15.340 of Title 5 (310 CMR 15.000) \ J I f Mailing Address: 2t 1_30..C. ��_ Telephone Number: —7k— D 6 9�V 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site wage disposal systems. The system: on-site _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails ,'7 Inspector's Signa e: :cti Date: S19� The System Inspector shall su mit a copy of this inspection report to the Approving Authority within thirty(30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to-the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria aS defined in 310 CMR 15.303. 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. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04/25/97) Page 1 of 10 DEP on the World Wide Web: http:1t*WW.magnet.state.ma.us/dep e'j Printed on Recyded Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property ddress: V O Owner: Date of Inspection: 2,_ S_ li l B) SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four 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 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 the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. _ The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis 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. Method used to determine distance (approximation not valid). 3) OTHER (revised 04/25/97) Pigs 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) PropertyAddress: k. ,_C �c �S ��Y���e S��.tC �A , ) Ct�,,��w Owner: � / Date of Inspection: CJ--t D] SYSTEM FAILS: You must indicate eitr,er "Yes" or "No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes Nod . 7 Backup of sewage into facility or system component due to an 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 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. v Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a 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 I of a public well. J 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS; You must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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) The owner or operator of any such system shall brine the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04/25/97) page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: Date of Inspection: I L j S - c�7 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Ye No Pumping information was provided by the owner, occupant, or Board of Health. — None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or // as part of this inspection. J As built plans have been obtained and examined. Note if they are not available with N/A. Z _ The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. J _ All system components, excluding the Soil Absorption System, have been located on the site. v _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. / The size and location of the Soil Absorption System on the site has been determined based on: _✓ _ The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of / Sub-Surface Disposal System. _ y Existing information. Ex. Plan at B.O.H. _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)j (revised 04/25/97) Page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property,Address: �sS �� ��P U'h2 � �Za •) � Owner: ycc y C,-r cA'�"r Date of Inspection: 1 2.--1 L Jc 7 FLOW CONDITIONS RESIDENTIAL: Design flow: 3JO _g.p.d./bedroom for S.A.S. Number of bedrooms: Number of current residents: Garbage grinder (yes or no):z Laundry connected to syste (yes or no):� Seasonal use (yes or no): �p r. Water meter readings, if av ilable (last two (2)year usage (gpd): (J ..s�7� �� . Of 6 Sump Pump(yes or no): 7 Last date of occupancy:QAVV7 w1 COMMERC IAUI N D U STR I A L: Type of establishment: Design flow:_gallons/day 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: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: AtnV'C., al 6 o��•t System pumped as part of inspection: (yes or no)_ If yes, volume pumped: eallons Reason for pumping: TYPE 30 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) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: ✓S Sewage odors detected when arriving at the site: (yes or no)LI (revised 04/25/97) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner:­��u.0 y Date of Inspection: 1 Z-IS 9-7 BUILDING SEWER: (Locate on site plan) Depth below grade: Material of construction: _cast iron Y40 PVC _other (explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK:_ (locate on site plan) . I(1 Depth below grader / Material of construction: �' Concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age _ is age confirmed by Certificate of Compliance _(Yes/No) Dimensions: In 24 1 d Sludge depth: i1 `'t 3 r baffle: Distance from top of sludge to bottom of outlet tee o `I Scum thickness: t� tt or baffle:�b Distance from top of scum to top of outlet tee Distance from bottom of scum to bottom of outl tee or baffle: _ How dimensions were determined: Y Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet structural integrity, evidence of leakage, etc.) (J.; i, GREASE TRAP: (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: Comments: for , condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural (recommendation pumping,in P g integrity, evidence of leakage, etc.) (revised 04/25/97) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: `7, S L;.�{>')b tt V� l�.•� .. !C�c :- c Owner: �� r oo(' C Date of Inspection: I TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or 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 level: Alarm in working order_Yes; _ No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:z (locate on site plan) Depth of liquid level above outlet invert:, `^�� Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) PUMP CHAMBER: (locate on site plan) Pumps in working order: (Yes or Not Alarms in working order (Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 04/25/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: J L-- f-6 —072 SOIL ABSORPTION SYSTEM (SAS):_ (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number:_ leaching chambers, number: _]L leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) f ti.l nA�v`t lvc 5 CESSPOOLS: (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 (cesspool must be pumped as part of inspection) 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.) (revised 04/25/97) Page 8 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: Z, -ci'7 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) (revised 04/25/97) Page 9 of 10 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: �G���h +✓-{� i/� „'{`��"� Owner: Date of Inspection: Depth to GroundwaterId 1-0 Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation. (Must be completed) u (revised 04/25/97) Page 10 of 10 t TOWN<.OF BARNSTABLE 179 LOCATION ,�-- �' ��i�s3c SEWAGE# VILLAG- ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. �G,�►v. 17 9a/to SEPTIC TANK CAPACITY 15 I LEACHING FACILITY: (type) 3 rlv %,, s (size) A-`x 30 X z ` D\ NO.OF BEDROOMS 2' BUILDER OR OWNER �r �c ' Czi-vzie°� V T a c��✓ ��t���®h t' 1 PERMITDATE: COMPLIANCE DATE: 9 v e Separation Distance Between the: O "� Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of'eac'aing facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by /5Dd�_ r' 2-x jo 0 Iq 6 000 f �� /qL Z. 3 a ASSESSORSMAP 'el op PAR L-70 N THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Di!ipviial lVar1w Tomitru'dwit runit Application is hereby made for a Permit to Construct (� or Repair an Individual Sewage Disposal System a .... . .....?.-,e.4o 4 .. -----------------------------------7?,#------------------------------------------------- Location 0"tion- \ "I / or L t N -1 _14A, ..ao�. ----- ....... 4 . .............. -�.-4d_�A 0*---- ------ ........................................... d .................. ......................................... �_l .....................�K_Ai3T Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms.........-3----------------------------a -- Expansion Attic Garbage Grinder --- Other—Type of Building 4Wd�_57'O".4—No. of persons------zR----------------- Showers (.Z — Cafeteria Other fixtures .../&- <� --------------------------------------------------- ------------------------------------------------------------- Design Flow.............//0.....................gallons per person per day. Total daily flow..........:U6------------------------gallons. 1:4 Septic Tank—Liquid capacitv./470P.gal Ions Length__A2,Y_._'__ Width------6.. ... Diameter......... - ...... Depth..4---------- Disposal Trench—No. .................... Width...... Total Length.... Total leaching area-----Y4.0......sq. f t. Seepage Pit No..................... Diameter-----.-_--._--._.-.- Depth below inlet.._......._......... Total leaching area..................sq. f t. Z Other Distribution box pj Dosing tank Performed by Percolation Test Results -_---_----------------- Date----- ......... ,� // ..... Depth to ground water.. & - Test Pit No. I 4_,�....minutes per inch Depth of Test Pit------Ile... .... Test Pit No. 2....�_2...minutesper inch Depth of Test Pit------/I........... Depth to ground water.-N-M. - ...........—-----I-------*------------------------------------------------------------ . --------------------------------------- Description of Soil....... .......ZAA, ----------........................................................................ e .. ....... U ................................................................................ ................................ ...................... ............................................................... ----------------------------------------------*-------------------------------------------------------------------------------------------------------------------------------------------*........ U Nature of Repairs or Alterations—Answer when applicable................................................................................................ ......................................................................................................................................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certif' t off�011ance lL4s been iiss ed by the boapj of health. s igned .. _____ __1...IV.-_ 4. Due Application.Approved B -------- jor�lw ------ -----------P_5�a- ----------------------------------- ---------------;--------------- Due Application.Disapproved for the following reasons: ................................." ------------------------------------------------------------.. -------------------------------------- .......................................... ...... .......... .... **--------------------------*­----------------- ----------------------------------- ---------------*-- ----------*"*------------ ........ Permit No. --t...*�----------------------------- --------------- Issued --------P__ W Due THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE ,�pplirativit for Bhip ial WDrk5 Tdt>1t itrUdio1 "Pun fit Application is hereby made for a Permit to Construct (//) or_Repair ( )..an Individual Sewage Disposal System at: - :. . w S y� LorJttion/�r dd•csg - No. e /_ 1 W 01�✓r7 /i A,1dddress / r ........_... a ............. .. %_:_ ✓!!�-••-•---•-----•---...................... ... !�G��elr�1!►-••----`----�---- !!r oh.c_.h�-i;�6 Installer ...__ 7 Q1 Address UType of Building 3 Size Lot.............................Sq. feet Dwelling— No. of Bedrooms------ Attic ( ) Garbage Grinder ( ) aOther—Type of Building lT1a .,�-_4 ?me>No. of persons-___---�2----------------- Showers Cafeteria ( ) Other i fixtures ---------------------------------- Design Flow-- _.__ _ /D....................g _ ____�,_. gallons per person per day. Total daily/flow----------�30---------------------.gallons. Wx Septic Tank—Liquid capacity_/4 gal Ions Length__ a.y Width------4____-_ Diameter_... .... ..... De th_.-------.. Width..--Z Total Length_ __ D__-____ Total leach ing area-----U _0.. ....sq. ft.Disposal Trench—No. ----------- Seepage Pit No________ _ __ _______ Diameter___.._ _--.__-_.-- Depth below inlet.................... Total leaching area.._..__...........s . ft.Z _ Other Distribution box ( V) Dosing tank ( ) -5 Percolation Test Results Performed b .. - .......114-&__________ _ _ __ S Y ----- Date ��=� -- --------•----- ,.. Test Pit No. 1....C_n2____minutes per inch Depth of Test Pit-------//_.;�- Depth to ground water_-ti"�2tt__- 44 Test Pit No. 2....5....._._minutes per inch Depth of Test Pit------ Depth to ground water_.!/one_..� N ---------=--------'----------------------------------------------------------- ------- - -------------------------------------- •...... •-------------- 0 Description of Soil------ ---- -—--------------- U •----•-----------------------•-••--------•----•-----•------------•-•---------•---•-•--------------•-•------•----...-----•----------------------•-------------------------••--------•••-•------- W x ---------------------------- U Nature of Repairs or Alterations—Answer when applicable-------------------------------------------------------------.----------------------------------- -------------•-••------------ --•----------------_...----•--------•------••-------•••-------------•----•---..................... Agreement. The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with �- the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certifi .te of -M fiance S been iss ed bythe boat of health. .i ned� eDate Application.Approved BY ....."'T"-..:..i'.."''... -..... t�,,, y►' :4"� . Date Application.Disapproved for the following reasons: t ........ . ............ . . .......... ...... --------------------------------------- ram^ _. Date" Permit No. .. ...... ..h 7. ---------------- Issued ------ D �. - •. °�+_ .� ate - J THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE .� .--- CTe>rtifira e of C11ompliance THIS IS TO CERiIF�I', That the Individual Sewage Disposal System constructed ( �) or Repaired ( ) by -------------------------------------------"----++--~- �_.. 1.. �'.......................... ----- -- -------- t ,,� / lnsclllcr mow, jai ............y�.....:T2nG� SP ��F// -- i ..f......... 1t .:.. �J- ..' . ........... .... hays been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in "the application for Disposal Works Construction Permit No. .. dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE---------------------.................. -�?_:�. ..............---------- Inspector ----- ; • -------- -------------------_------------------- ------ THE COMMONWEALTH OF MASSACHUSETTS j 0o r " BOARD OF HEALTH I '7e TOWN OF BARNSTABLE No.................... FEs ............... Diiipvii tl Workii Tun trurtion Wrmit Permissionis" reby granted------------_--- -- � �a ��a----------------------------------------------------------•----------------............. to Construct �t� orRepair ( ) an Individual S�.wage Disposal System _ at No.--•--•.. ..... ?�o ® } ` ' l n +�r.1� .ZG =5 street �,� as shown on the application for Disposal Works Construction Permit_, o�___��Dated.._.�." .�_- ....`":,,�'7�7 C..._,_ �..... r:.. :-`r------------------------------- ----------••--------------•------•---...._... q Board of Health DATE---- --------•- FORM 36508 HOBBS&WARREN,INC.,PUBLISHERS / i =— -- --- - 511011 36' 0" ------ I — — — — All walls 8"x 7'9" on 8"x 16" footings except 12" walls as noted. Concrete 3,000 PSI, 1/2" anchor bolts 6' o.c. °O LO to be located 3" in from outside on 8" walls and 2" in - 151011 _ from inside on 12" walls. 24'4„ O 18'4„ li 12'6 i 6,9" i 3'x 3'x all pads 2'x 2'x O \ ,'pad ,'unless noted - , ' I ,2"Walls O O 00 i N M I Beam Pockets ® ; \ flush girt, no pockets 141011 CO _- \ i) 331011 2,4„ 0 0 o 20 12' Wall T- 18' 0'' !' - — — — — — — — — — — equal equal equal - _ _ - - - - - - 181011 10"sonotubes on 2'x 2'pads V APPLICATION FOR PERCOLATION TEST AND OBSERVATION PITS LOCATION �n� 7QA pnbil/F.S�TET,y _ NO. VILLAGE 1 DATE.,5 APPLICANT -7 /�Ff� TRH✓E�c FEE Z'j9. �_ TELEPHONE NO. (Non-refundable) ADDRESS / ENGINEERfT s'o�✓ f �y��� R•S• �/�����rd TELEPHONE NO. �7 DATE SCHEDULED (Applicant' s ignature) • • •• • • • • o e o e o • o • o o o o e • e . . . ... . . . . . . . . . . . . . oSOI o LOG• • • o . • • • o o o o o o • o • • • o • o• • • o o . o • • • • • e ASSESSOR'S biAP & LOT NO: SUB-DIVISION NAME DATE )1/ /9�_S' TIME /`,� _ ) d�i�'► T ENGINEER EXPANSION AREA: YES NO _ l'Tc�.r-s - _ _ - •-- TOWN WATER�PRIVATE WELL F!J f�I�R/ ��in�T )� F BOARD OF HEALTH EXCAVATOR SKETCH: (Street name,etc. ,dimensions of lot, exact location of test holes and percolation tests, locate wetlands. in proximity to test holes) NOTES: AV Po p O Nf s� /a�.�� • gA • � po n a VJ .t PjkCOLtiATION RATE: ' / ELEVATION: TEST HOLE NO: ELEVATION: TEST HOLE NO: 0 • U �OJC/ZDi✓ l O �'. / O � — Q ,�IOR lZ •. 3 3 — P- f�a.p!r-o U Z n— �oR!Z rJ i✓ 4 12171 — O C -/Yl f6 tJ q W/A 9„ �a,, 4 6 l�yip 5 - / ,5.. / � Z 0 �O 7 G 7 8 F 9 9 ! 1 0 10 --12- — — 12 13 13 14 14 15 .15 ' 16 16 SUITABLE FOR SUB-SURFACE SEWAGE: LEACHING FIELD LEACHING PIT'S LEACHING TRENCHES UNSUITABLE FOR SUB-SURFACE SEWAGE. REASONS: NOTE: ENGINEERING " PLANS MUST SHOW NUMBER ASSIGNED ON PERC TEST APPLICATION ORIGINAL: COMPLETED IN ENTIRETY BY P . E. AND RETURNED TO BOARD OF HEALTH r•n.n ; . 1?7,111.nTPED BY APPLICANT n 1 � a - 0 OT b_ LF o V _ d ,�. � F r i i . I • C � T FS SV41 L- 14 60 a � a ©�. �w \ / I e r✓ . E; F E��✓G Lai 7y el '0 F x s'/'o 'r, 11z1' '-V 401-7,9n/ f•+'fla..�L d"J t t Ir✓ J�z,,*,v �.r.,z , 9GF -.502, } its 4\ ri } 1 1 .'h Rod 3 t 4 fir, �IF6 oK 000 f41\ 6;1 g� ©o.5'" e � /+ f 7 _ ,...{.ss.: ...4L'....... ......?....'c:.,...+.i....e'.Y ..:..r,_n.Y .W'.-..:e... --..,-.t.. ..-r,_ •... ..:.-.... ... _ .fho ,. ,... .t. Y .2+,=,• wr3...wacv*.'ity TOP OF FOUNDATION CONCRETE COVERS 1 / �. I / ��: 4"CAST IRON 12"MAX. OR SCHEDULE 40 4"SCHEDULE 40 PV.C. (ONLY) " - 1 P.V.C. PIPE MIN. 12 MIN, 2.3 w *•• PI PIPE-MIN. LEACHING TRENCH ......REQUIRED) -'ally er, /-°G Ja,a / / f , r� PITCH I/4 PER.FT PITCH 1/4 PER.FT WASHEDMSS1ONE - �� T - .• IN INVERT , /f.. wp,Y ! o y • p a •� r1 ae SEPTIC TANK � c� .. INVERT % �'/. ' . ' /..TQ��. GAL.. INV�F T x CG47.2 E3 0 \ I'� { '.; EL„Sl.•.�� El..'ic.77 INVERT INVERT \ EL...,,.�.. .. , ., • .lz e3 72oovc. LJn/L� '.�'{ Ze,ai,< F //a.✓n c.✓<oc�n/;C PROFILE O 'T";,/sC . m�S%•�?a GROUND WATER TABLE SEWAGE DISPOSAL SYSTEM TYPICAL CROSS SECTION SOIL LOG No SCALE LEACH i NG TRENCH ` DATE41`J 45'_TIME O•`!''J NO SCALE' TEST HOLE I TEST HOLE Z - yyQ DESIGN DATA ELEV. ELEV. r tle=I/2" . .. . . 12 MIN. WASHED e" D�'r" osiZ. c->D C� ,r/c •Z NUMBER OF BEDROOMS . . . . . . . . . . STl�NE SITE PLAN COTUIT, MA t N - -:_ �," � •� ��'� ip-•,�,+• ��•�; TOTAL ESTIMATED FLOW . . . . . ��..1��r.. GALLONS/DAY �C� ,~ . /'7t,7• � BOTTOM LEACHING AREA . .. . . R4 .. SOFT,/TRENCH . ro r� lS�lwf� FOR SIDE LEACHING AREA . . . . .. . .!<04�. SO.FT./TRENCH — .; GARBAGE DISPOSAL . . .evLq . ..(50% AREA INCREASE) WASHED I .:� .Zy��L J✓y,�, �".§, ;4,q y�`JZ'� STONE ovE� / y � ..✓/��ch TOTAL LEACHING AREA . .. . . ."?�h�.: SOFT. I /y 7' T P A C l�/ C C. PO 1✓ E R, ,� j� �• �l eA —�--- :.; d•,A�✓D PERCOLATION RATE . . . . . .. . .�. .t-•�.. PER. INCH 1p -7 /`' �� • E aJ,� LEACHING AREA PER PERCOLATION RATE . �l�,. SO.FT,J�Y�� �cv✓G !�� �, /Z E4: ' GROUND WATER TABLE t APPROVED BOARD OF HEALTH F YO..WATER ENCOUNTERED DATE .p Ffgss9C� ,'fr - AGENT OR INSPECTOR .�� �c /C? EDW R6 �s WITNESSED BY : LL LEY "' �fO. ''^Y �n/�fi9cS��C+f_. BOARD OF HEALTH . . = N I y► rr o. 261!]Q CTrfr c3 r�/��, � liC L •l�-s . ENGINEER AL LRKQ� ' . . . . . . . . . /SANITAR�P��� PETITIONER ►���� ✓/ /'fig 4o6,3 zS' v rw':awk.w..zr ... -':.' .•. k , .- ,.:.:. .: '.' ,. ..:. iC .JAy 1 ..;GW ryq Y«. - h i . ,.... ;5r Ji,.n., �4.;..,..,.x' -. .. •:.. -.. :. -.. 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