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0030 QUEEN ANNE LANE - Health
30 Queen. Anne Lane Cotuit F/R A = 022 121 --- - ---- -- — - - - — -- �\ t: f i _ TOWN OF BARNSTABLE r LOCH.SON [o� '�—�.( 4M ofcr " SEWAGE # 0LI-- S 11L U VILLAGE L6-7 +-l- ASSESSOR'S MAP &LOT !mil- INSTALLER'S NAME&PHONE NO. ���n—��t �1 f ! -7-71 SEPTIC TANK CAPACITY OM la.� LEACHING FACILITY: (type r L&-j lGt f 'rL i 6 ,uj14(size) NO.OF BEDROOMS BUILDER��:9 L--kll-� PERMTTDATE: COMPLIANCE DATE: 12l DZ Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 14 A-- Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) A Feet Edge of Wetland and Leaching Facility.(If any wetlands exist within 300 feet of leaching facility) � Feet Furnished by f ' 4 •tf,�.4 30 A of -' TOWN OF BARNSTABLE LOCAT11QN -50 Jdrow g-' 4 Q✓r SEWAGE # VILLAGE (_ tl A,r ASSESSOR'S MAP & LOT"2 Z2 / INSTALLER'S'NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER O OWNER �/.' aLirre C r PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: 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 leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by / t/ / .S a� r-✓ f i o �o � � O Fee BOARD OF HEALTH e TOWN OF BARNSTABLE `/ w application ,for Yell Cou.5tructtou permit Application is hereby made for a permit to Construct( Alter( ), or Repair( an individual well at: `y 30 Q c t a eru G .ti•v L rJ (.oTL iT Location-Address Assessors Map and Parcel P r C 3 o pueL--j oT rT Owner / Address enln/ iS & a,,j-v e (� !D� 0e&,,C,.fi /�� AAwZPee Mee W6 Y� Installer-Driller Address Type of Building Dwelling✓ Other-Type of Building No. of Persons Type of Well 4/ /w C Capacity Purpose of Well I/ /`r C,Oro „y Agreement: The undersigned agrees to install the afore described individual well in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation-The undersigned further agrees not to place the well in operation until a Certific of Compl.ance s been issued by the Board of Health. Zp Signed Date Application Approved By Date Application Disapproved for the following reasons: p I •—� Date Permit No. L/✓ "' y� Issued Date BOARD OF HEALTH TOWN OF BARNSTABLE (Certificate of Compliance THIS IS TO CERTIFY,that the individual well Constructed(/, Altered( ), or Repaired( ) by Ae ru ,u c q SGa ry.yC Installer at 30 Q u e e•v ot ti-j GoT i 7- has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Prot ction Regulation as described in the application for Well Construction Permit Not3� "a1)®? Dated l l 1-2 THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORILY. Date Inspector -- ---------------------------------------------------------------------------------------' 7It ,)Y t�}''� Fee �`"�`c"9 BOARD OF HEALTH .T OWN OF BARNSTABLE � 2pplicatiou -1 r Yell �lCou.5trurtton Vermtt Application is'hereby-m de for a permit to Construct(�); Alter( ), or Repalr( )` an.indlvld "al well at rJ f a. t✓' r Location-Address s Assessors ap and Parcel w. 0 J s M L, 3 v(Z5 Lj e Pij Owner Address r1Pr!�i�'i iC � G�fN K• C �/ /�(P' rlP�n/�a�' /�� �t'�S(n/�Pt° /uU UJG y� � i i Install el-Driller Adress i Type of Building Dwelling t _ Otlier `Type.o'fBuilding 6,_-*r,:.__.. . . No�ofaI'ersons :c .. �, -3 w.:. :Type_of.Well -412 1=r I E. - r+_,.ri.- :- ;.,.,. .;.- -Capacity-.-- Purpose of Well I r /' Agreement: The undersigned agrees to install the afore described individual well in accordance with the_provisi"ons-of the"-- -_— " Town of Barnstable Board of Health Private Well.Protection Regulation-The undersigned further agrees not to place the well in operation until a Certificate of Compliance as been issued by the Board-of Health '' ' YJ CA Signed �1 / 1' �? a �_ 9 a p• :;� Date `PP PP Y A hcation A roved B . _ Date �3. Application Disapproved for the following reasons: t Date Permit No. i.1�t d �' Issued Date �� ..r �-tom ----._'-"-� �..�+.�"'�zT;�.#�*ii.�..•:r!'.�,",.�`,. i,.....'..,.e«.�®.o�.a.�,«-®_s... -v��' - i�" - --. _ -_ _ _-r-^-...-y,.,..•,-_.� e -•- —" BOARD OF HEALTH .r TOWN OF BARN,.STABLE _ �erttficate of Comp tauce THIS IS TO CERTIFY,that the individual well Constructed(vf,, Altered( ), or� _ Repaired( ) r by, / f#U/U 0? S("d 4V AJ[ ! / g x, Installer r. at 30 0ver j has been installed in accordance with the'provisions of the Town of Barnstable Board of Health Private_.We11.Protection ' x - Regulation as described in the application for Well Construction Permit No q �.t 9� . Dated l.` THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORILY. Date ' Inspector a y=�•-_ - _._�aw�__ A----------- aomoeeeeoeoe-----a ------------mose>o--roe--eoe0e0ogemememeeoeeeeeo-- BOARD OF HEALTH TOWN OF BARNSTABLE Yell Cou5tructiou �eruut No. ""`✓ i _ f Fee . , 4 5' r Permission is hereby granted to Af A-)/\)I,S Installer to Construct(c-); Alter( ), or Repair( an individual well at: No. 30 (D y P f y q w.y Street as shown on the application for a Well Construction Permit No. IJQQ� Y3 " _ Dated 1 i I I-?/ Date / ( Approved By.,, ,Q l oU O , !ff F 3 � w c (� i R E No. 0 Z— Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS es 01pprication for Mi5poe;al *pgtem Construction Permit Application for a Permit to Construct( . )Repair( )Upgrade 4 Abandon( ) ❑Complete System "dividual Components Location Address or Lot No. QGl�O Owner's Name,A re and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.Po. Designer's ame,Address and Tel.No. Type of Building:Dwelling No.of Bedrooms_,� Lot Size 2C.9 _ zz sq.ft. Garbage Grinder(_4/0 Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow 3:5Z,1 gallons. Plan Date 0Z, Number of heets % Rev' ion Date Title Size of Septic Tank .0®0 ���5 Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) v l stg Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by thi B He / Signed Date J�C Application Approved by Date o Application Disapproved for the following reasons Permit No. � v a a- C:f26 Date Issued Q— --------------------------------------- w NoaUaz - Sys S� = > �, Fee . THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: floes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS z° Zipplication for Mi.5poar *pgttm Con6truction Permit Application for a Permit to Construct( )Repair( )Upgrade(�)Abandon( ) ❑Complete System "dividual Components Location Address or Lot No. 3� Owner's Name,AdlreWand Tel.No. Assessor's Map/Parcel co .,c Installer's Name,Address,and Tel. .o r Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size 20S�3sq.ft. Garbage Grinder( ��O Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow /Z2 gallons per day. Calculated daily flow 33o gallons. Plan Date It f3'M Number of sheets / Rev* 'on Date Title C�' e ; , Size of Septic Tank . (2 00 4Z4 1'5/`% Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) / /lam �!L U0,71aA 7� r Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this B azd.o He lth ." Signed 1 Date Application Approved by ��5. _ Date /.? J ?`o� Application Disapproved for the following reasonsV Permit No. a) o v -17- S::f2-6 Date Issued 23-d Z --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTj�IFY, that the O'�'-/site Sewage Disposal System Constructed( )Repaired( )Upgraded(✓ ) Abandoned( )by !g111 D lT) �!� S at 30 O -ege 67h/ ze 4 1 Cd l//T has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No..2d a.)-1-96 dated Installer Designer The issuance oIthistrmit shall not be construed as a guarantee that the syste 2wi ;IuWqo2!9signed. Date �2 �- Inspector --------------------------------------- No. o?fJ Fee •.�� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Migo$af *pg;tem Conotruction Permit Permission is hereby granted to Construct( )Repair( )U grade( )Abandon( ) System located at �O n"e_Q, Xiu (u and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of th' _ ermit. r Date:_ 1� d 2 /d 0 Approved by I TOWN OF BARNSTABLE LOCATION ,&MMI AKI KI L SEWAGE # VILLAG ASSESSOR'S MAP&LOT INSTALLER'S NAME&P) ONE NO. 's-���—Q�t �r,�( -7"7 SEPTIC TANK CAPACITY 1-�fe-(S-7-1 ��1 LEACHING FACILITY: (type _Izc-(site) A ' NO. OF BEDROOMS BUILDER 6 .L k� PER.MTTDATE: COMPLIANCE DATE: I`Li p2 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility llb= Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) ►'J �- Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by I i 10 --�i G �I R � ` 11" a k Town of Barnstable P# P o� Department of Regulatory Services BAANSTABLF. Date /) . ,Nr„ya Public Health'Division 200 Main Street,llyannis MA 02601 Date Scheduled V;- Time U Fee Pd. go. soil suitability Assessment for Sewage Disposal N p-)pT E Witnessed By: � ��.�•S j N i�N Performed By: .�' NMI : .' ,q,• r �� '• It ! � a I R MIN 3�"�4'I!a4I'Pa d 1 ,�. k aeN "' Owner's Name Location Address i Address t" �. N I Assessor's Map/Parcel: Engineer's Name ()ow i G� O 2'Z -� � � NEW CONSTRUCTION REPAIR V Telephone# rj Surface Stones Land Use (j Slopes(%) Distances from: Open Water Body ft Possible Wet Area______ft Drinking Water Well ft ft Other ft Drainage Way ft Property Line ,�— SKETCH. Street name,dimensions of lot,exact�9catlons of test holes&pert tests,locate wetlands in proximity to boles) \21• 20i 1 / Y oo ©��aSl-, ,p\q�1n Depth to Bedrock ?ZBt7 Parent material(geologic) 1 N /^ Depth to Groundwater: Standing Water in Hole: N C�/J C Weeping from Pit Face Estimated Seasonal High Groundwater a1 �i5a,v! ul� yN ^ a 4 1, .. Method Used: 1D' in. Depth to soil mottles: R. Depth Observed standing in obs.hole: in. Groundwater Adjustment Depth to weeping from side of ohs.hole: -' '' pdj,factor`. - Adj.Groundwater Level_ Index Well# Reading Date: Index Well level* — ff Observation t a ^ Tirue`at 9" Hole# ' i Time at 6" Depth of Perc o 0 Time(9"-6") f — Start Pre-soak Time® a Q S 00 End Pre-soak �2 M NA to Rate MinAnch Site Suitability Asse ssment: Site Passed Site Failed: Additional Testing Needed(Y" n ,,u.,TT—w,mvision Observation Hole Data To Be Completed on Back-- 1 wr. t ,,n•.5MEN r. i #iI�t j4 r t• " E:•5' . #�I I i �I:Fia �47� II C N 5IC$ Depth from Soil Horizon Soil Texture Soil Color ! �Soil � � Other•r - Surface Cin.) (USDA) (Mansell) Mottling Structure,Stones,Boulders. Consistence,%Gravel) T- n��o" �ia��r LS � • to �3 t o- ILA A N"36'` ��'Lp`' G 1 J�(� SAND �--S � • 'V v New 'r t I ;I� I I�ti� {:�I � ,;�: f � .3. cl•" a Soil •� ..�i_ �:,. : ' �1��=`. • s�v l�l� _ 1' �� hb 011 -..Other om Soil Horizon Soil Texture Soil Color De W fr p Mottling Structure,Stones,Boulders. Surface (USDA) (Mansell) g nsistenc %Gravel ! ...:' � :•n�.l � ne A� .,��: :;v• 'r'. a.,,..� "�I"v •atiepl�m Inflra,; n,:t>r rr'tl I r��,�•tltl�tl�"�,M ,';�": 7. ti����,•5� 6NWI;:t 'F CQ �WMr_.11�R� FI i �.b"6591u, r't� :. 91�x�.F6�rv� sOd^ Other .. t ' Depth from Soli Horizon _ Soil Texture Soil Color Mottling Stmctu re,O Stones,Boulders. Surface(in.) (USDA) i (Munse�) � Consistene °/b Gravel � t , A _ tlTi u' '3 y iil'�� II " I ;tft Soil ` .Other O Depth from Soil Horizon Soil Texture Soil Color Stones,Boulders. Surface(in.) (USDA) (Munsell) Mottling Structure, Consistent %Gravel Flood Insurance Rate Mil)"' Flo �` � - .' � . ' t -, • Above 500 year flood boundary No_ Yes W Y Within 500 year boundary No Yes ' Within 10o year flood boundary No— Yes Depth of Naturally Occurring Pervious Material. Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? „ / 7 i' If not,what is the depth of naturally occurring pervi us material? ( _ Certification c, I certify that on /\JO V\ (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with W the required training,expertise and experience described in 310 CMR 15.017. �rfown at1'.Biti-IISl�ble. !, '� A' Ue inrlmcut.of Ele,hi(li Snfet 'l. , y, nud.CnvlroinUcnlnl Set•,'iccs. ,Public Health pwisiolh <. a;Ite J6.7 Main Slrcct,i tyminis MA 02601 AIMS f629. �e'g p iyT j (Jp .� �Arto►nnt" mate Scheduled: lilac �. �:r« f ce I'll. s � Soil.Sccctabilct Assessiri.err,t o�� Serva e Deosrr.l 1 f . ,l 1'crfonncd Ily:__�3zuc C a7i 19c.� Q;E 1Vlincsscd Uys :I�uc 54".k-In__,_y 1 . o 0CATioN &UPNERALINZ+0104A`ION (� Locallon . . Owncr's Nome �enh(r r 12t i � Address `19 S ma r.ti S�r'ra,i�'. 2re C7 AddressLA rs�vv►�1v"° Assessor's Map/I'nrccl: 27 I?n9hicet's Name,JEeu,fz, AJ,a�,� twa�i.zw N(aV CUNSI RUMION RrPAIR Telcphonc ll .Swim—Aur-1131 . Land Use ae9<44e , *_a Slopes ,SWtics noytz _ Dislnrices from; Open Witter Body it Possible Wet Arco (1 Drinking Writer Weill. I1 Drnilinge Wny 11. i'ropcity,l,lilc : it Olitcr _ II SKETCH: (Slreei amine,dimcnsions of lot,cxnct locnilons of test holes R pere tests,locnte we(latids in proximity to holes) D, � 2 _ ys\ bi' t` Ix' \\ ,P�; 193.11'1 \ Al �_R---�43' p 1 '3 a b t\ iq r�,wD�woOo R ah w b@ � a• a } J �,(.a"• r\N� r a°ah a c�° b bah C '\\ \.�\ }Q� �. . • �5.7�' \.Ph' ,'Z \ \ CidS \ �, iR 0 LL + 1 \ \ \ ��''�, ' r,+ it 'a }�` b.• �+J aQ \iN0..� �� ab'� ii - 42 �^ W l \\\ \, \` }'. \i �` CfJi➢e as POR04 \� +a}/ "^ + a / -- Qt• 34.01 +}2 \\`'\ �1� \a}o 1 +ah O as a�4 aP Z }O 4 1 `1 Ptio 4p ,y � l� 12' m. W \ ' Pa• }a`N IS'S8'19� W 1 37 Q4• YePy I'nreul innlerinl(geologic) C(a mtat 64}L»s:t1 Depth to Redrock Depth to Groundwater; Stnndltig Water in I lolei Weeping from PR Pnce Gstininleil Seasonal(high Groundwater > <:>:::' U1 �tI1XN 'Z?ZCJ. :>; ( Zt SSONAL 'IZIGIZ•� :A13LL Method Used: In. Depth to oil Io,*Ueplh observed s(mtding In obs.hole: Depth to wccphig froth side of obs.hole: In. Ground..mler Ad.iuMment It. .r IndA,Wcll N _.:. Rr.nding iJnle:_••__ Indcs Well level ^_ Ad•l.'rnclor . J.(iron ndwritcr I,cvcl .. �'C�tCUU ON �CSi z,'rnuc io a.�1 observation . I tole N Time nl 9". . Depth ' of Perc Inw nl G' Stott Prc•soSkTime @ /o:64' End Pic sonk,'' /o.'i u,e. A G .'e�J Sid us c�, ZH yo�lcre.o . Rnle iviiit.linch { Site Sullnbility Assessnienl:..Site Passed i i ite_ Site I:nilcd: Addillonnl'I'csiing Needed(Y/N) Urighinl: Public:ltenkli Uivislan Ubscmdon Hole Dn(n.To ile Completed on Mick j Copy: Applicant l .. .. .. ...... S AjG V 6�. ..... .............. Fm Depth from Soil 4lorizan Soil Texture' Soil Color Sot Olhcr Surface(in) (Munsell) Mollling< (Structure,Sloncs,;Dottideres. Consistency.c 43 G : bEl 17I3SLIt� 'Z'XON HOLD'LOG Hole# :.: Depth rroin So1(Florizon So117 exture Soil Color Soll Other Surface(in.) (USDA) (Munsell) Mottling (Structure;.Slones,Doulderes. %Gmycl b (J� StVA'I' (�Nbl� Lq 4- got Depth from SgII I'forizon So11 Tezlure': So11 Color - Soil Oilier Surface(In.) (USDA). (Munsell)` Moltlimg (Slruclure,Stones,Doulderes. _ e .. I el ' : D��� Ol3S�H�A.TI(�]`V kIOLL T�U.G. . ....: Depth from $oil t{orizon Soil Texture Soil Coloc Soil Oihcr' Surface(in.) (USDA) (Munsell) Mottling. .(Structure,Stones,Doulderes. . n •i Flood hisuralice Rate Man :. ti Above 500 year flood boundary No_ Yes Within 500 ctir bound ✓.: y No d/ Yes Witldn 100year'Oood.boundtiry No 'Yes ntli of 1Vsittirally Occttrlre Pervious 1Vlaferial Does at least:four feet of naturally occtirrtng pervious material.exist in all areas observed throughout the area proposed for the soil absorption systetn7' :ycs If'not what is'the:depth of naturally occurring.pervious material? ' �eYtiCicattou:. � i I certify that on 4: .:�5 (date)I tiave passed tiie soil evaluator exanuitation approved by the Oepartmcnt.oIFEnvironrnental Protection and that the above analysis was performed by.ine consistent with, the required training;:expertise and`experienct described in 310 CMR 5 Ol" 01, Si nature Date !Z rri OZ �v nU . te. LOCATIONa SEWAGE PERMIT NO. VILLAGE INSTA LLER'S NAME & ADDRESS (7 -- p r�twdew�t/ Cadlf�}D`[OsL PF�9 `l ��� I ^J BUILDER OR OWNER bA ysA T M ow 14�t DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED �._ � r -3:5 ` � a tb 4a� f ed No. ��...... / Fmis.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF.................ao� ... .............. . _ ...... Application -for Diopoal Workii Tonotrnrtion Puniit Application is hereby made for a Permit to Construct ()(-) or Repair ( } an Individual Sewage Disposal System at: �"Aw *4N&r 44 Cv0/T 4. r 0 AlAlar 7 ----------------------------------N.......--pp------------------------------------- ------r•-------•••••-------•-----•--•. .4...---------------------•--. L�ajtion- ddt'ess or Lot .40A?f/.�J__9` !4ie/ ' 4 c.l ot.�r� ! - -------3- C��---�--��-'-`/ S`�' �Q :l .. t g/+dOL......� 0�A...._ � ®�• xr„ Installer Address r U Type of Building Size Lot... feet Dwelling—No. of Bedrooms___________Z-----_--------------------- Attic Garbage Grinder (co40ViivRc47rV aOther`=Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures WDesign Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons. WSeptic Tank—Liquid capacity/d.oB__gallons Length---------------- Width------.......... Diameter................ Depth_--__._...---- x Disposal Trench—No. .................... Width-------------------- Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No________________--- Diameter.................... Depth below inlet____--__._ -_--_-__ Total leaching area.-_-.--.-----__---sq. ft. Z Other Distribution box ( ) Dosing tank ( ) '- Percolation Test Results Performed by.•__---77 WJC. V/OYAe----- Date...... A a Test Pit No. 1---i_•� ....minutes per inch Depth of Test Pit..... ...... Depth to ground water------------------------ �14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water_-.-_-___-_--.-__-_- a ----•-•- --------- -------- ---------------- -----•.--------•--• ----••--- ------------•--•-••------•-•--•----•-•----.-.---•.-----•-••-•-•-----•--- G Description of Soil---------- T,r��__..eelAi 4..;AIwa---- ;l®.1P A° S.WO - . �Af' LA/�.��4._©If-; ` x V - -- -- ------------------------- 6cc�it/or�.iC / i�lrof/G 4 J ✓��t�t';ro._ dl-- - ac, ------c--- - -------------------------I�-------------------------------- ------------- V Nature of Repairs or Alterations—Answer when applicable..-r�-.__C�w��T_-.__..�/fi•./ ��/sr ------_ ------------------ ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article NI of the State Sanitary Code— The undersigned further agree not to place the system in operation until a Certificate of Compliance has b _n ' sued by the oar of h th. Signed -•- --------i....... ------------------ �/ ate:o Application Approved By_. :��________________ -------------------------------------------------------------------- Date Application Disapproved for the following reasons:------- %....----•-------------•--------------•---------------------------------------------------------------- ----••-------------------------------------------------------------------------------•----------------------------------------------------------------------------------------------------------------•- C Date PermitNo.__S A./---•------------•-•-----•---•---........ Issued........................................................ Date wa i No...... ..- ! ..... 4 FEa.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH _.. .. ..._ _. .............. .OF......................................-.-.-..--I.............---.......-.-... ......... Appliration -for Biipoottl Works Towitrurtiou Veroiit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ........................................................... Lo a ion- ddress M or Lot No. �' J ------ c-.�o w.A. ............................... SOwner ddress AG !�T_ili/T 45' fr!�p flA�d�A✓--COWr, �16 >�AIC............ .. qPQ Installer Address Type of Building Size Lot-.-12!? -�...Sq. feet U Dwelling—No. of Bedrooms............. .............................Expansion Attic Garbage Grinder Other—Type of Building No. of persons-----------------------_---- Showers — Cafeteria 0.1 Other fixtures ----------------------------------------------------------------------------------------------------------------------------------------------------- d W Design Flow............................................gallons per person per day. Total daily flow................................_...........gallons. Septic Tank—Liquid capacity4f�'� U --gallons Length________________ Width__......--..... Diameter................ Depth...------.------ xDisposal Trench—No. .................... Width-------------------- Total Length-------------------- Total leaching area....................sq. ft. Seepage Pit No..................... Diameter-------------------- Depth below inlet.................... Total leaching area._-----___.-- __-sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......77!N M. :+��1_-.. le. lfiAg..... ���� E't�Jv_. Date------- Test Pit No. 1... !S-_--minutes per inch Depth of "Pest Pit...../2-...._.. Depth to ground water------------------------ ' fs, Test Pit No. 2----------------minutes per inch Depth of Test Pit..-___--_----___-_- Depth to ground water-_.-.-------.---.----_- -----------•----------_ -------------------------------------------•-------•------------_.._.------------------------------------------------------------- O C0A -• - - •A � C p Description of Soil a�� -------------�----SA A! --•�•----A• - --4=� ---!oqw--- �-�---6J?A? LAB'- °----,rit -jx x W V 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 Article XI of the State Sanitary Code— The undersigned further agree not to place the system in operation until a Certificate of Compliance has ybbR��njsued..by the •oar of health._Signed- - a;< Application Approved B �Y-� Date Application Disapproved for the following reasons:-----•------------------------------------------- --------------------- ........................................ --------•---•------------•-------------•-------------------------------••-•-------•---•-••••...-•-•-----...---------------•-•---......-=---------••----•-•----------------•-----.....---••------------•. Date PermitNo----- ---- ---------------------------------------- Issued........................................................ Date I THE COMMONWEALTH .OF MASSACHUSETTS BOARD OF HEALTH < tr f...'. .......................oF..._..-f:.. ............. ......................................................... Tertifirate of 10.1,11IMPha to THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (i) or Repaired ( ) by---..= -----• C-''i/"/��ti v .--- Installer at - - - ------- • —�,/ has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit No------!' /--------------------------- dated................................................ THE ISSUANCE OF THIS CERTIFRCATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WIL-L- FUNCTION SATISFACTORY. cDATE - ------- ------------------------------ --------. Inspector-------•�- j--}-----�•-- fit ------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD/ OF HEALTH .................... ../.Gt............OF......).1-1/.. ; ........ � / p No.......................... FEE•Z-'................ DinVoiial Morkii CITTonMrortion Vrrmit Permission is hereby granted-----------ram!_-`� �.!---:•--•---_._r'--- ' [�`_? l":------------------------------------------------------ ----•---- to Construct (� ) or Repair ( ) an Individual Sewage Di//sposal System at No. ! ---•-- i Street JDated as shown on the application for Disposal Works Construction Permit No--------------------------_- Dated________ -----------•-------------------------------------•--------- ........................................... Board of Health DATE----------------------------------------------------- - /',d. /s c /V 1 �-,...,/ii/cam .G•. L / FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS XA �jL/ T G Ci C t?i_s1ti� /l t �l, ,w✓�. _ t�f� ►f. _ �dt�� ��r ' �/- /1��r I . i - II � '. � ' S�c�i i� r�•C' f' '` it I � co J-71 rV - Co o i N ST -- i..-� fib` '�� `,,' •,,,� ��. COMMONWEALTH OF MASSACHUSETTS 4 EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS h" M c DEPARTMENT OF ENVIRONMENTAL PROTECTION a FAILED INSPECTION TITLE 5 OFFICIAL INSPECTION FORM.-.NOT FOR VOLUNTARY:ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM1 PART A CERTIFICATION MAP Property Address: PARCEL LOT ' Owner's Name: lyzi Owner's Address: Date of Inspection: 96 ICJ a � ^ .,� vZb Name of Inspecto lease print)�o b�r-� -6Of'o64°� NOf/ D ame: �'Company N � Ul . Mailing Address: 6 Telephone Number: v� FpT, h�F 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 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: /l (v/W a The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer; if applicable,and the approving authority. 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 6/15/2000 page I t P Page 2 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION continued Property Address: Owner: ' Date of Inspecti _ Inspection Summiary: Check )1,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'1�.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 infiltration or exfiltration or tank failure is imminent:System will pass inspection if the existing tank is replaced wifh'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 will pass 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 r Page 3 of I 1 OFFICIAL INSPECTION FORM-.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM .PART A CERTIFICATION(continued) Property Address: , Owner: Date of Inspecti j 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 f a-'ccofdance with 310 CM,R 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 satt.marsh 2.. System will fail unless the Board of Health (and Public Water Supplier, if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil.absorption system(SAS)and the SAS is within 100 feet of a, surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS.and the SAS is within,50 feet of a private water supply well. _ 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: 4Q _!/ C. Owner:{ Date of'Inspectio : ` 7� Ua D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: J No L. 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 ''/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 Any portion of the SAS,cesspool or privy is below high ground water elevation. V An onion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface Y P P P �'Y PP Y Y water supply: 1/ Any portion o_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 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.] 1 (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as - described in 3310 CMR 15.303,thereforeAe 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. 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—I WPA)or a mapped Zone 11 of a pu')lic 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 1.1 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE`SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: -1�2"A- 6/)L_L Owner: Date of lnspecti a Check if the following have been done. You must indicate"yes"or"no"as to eachof 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? 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 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: Yes no — 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 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS 'SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: x. /.l./X, k Owner: , Date of Inspection. 000 a FLOW CONDITIONS RESIDENTIAL, Number.of bedrooms(design): . i� Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 11.0 god x#of bedrooms): Number of current residents: Does residence have a garbage grinder(yes or nqZ. g Is laundry on a separate sewage system (yes or no): .[if yes separate inspection required] Laundry system inspected yes or no):_U— Seasonal use: (yes or o.. / Water meter readings, if available(last 2 years usage(gpd)): Sump pump(yes or tiy0 v Last date of occupancy: COMMERCIAL/INDUSTRIALL/)(b— Type of establishment: Design flow(based on 31:0 CMR 15.203): god 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 part of the inspection(ye r no If yes,volume pumped: gallons'--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM LV§eptic tank, distribution box,soil absorption system Single cesspool _Overflow cesspool _.Privy _Shared system (yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology,Attach:a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach a copy of the DEP approval _Other'(describe): Approximate age of 10 1 c poZM ate installed(if known)and source of information: , Were.sewage odors detected when arriving at the site(yes or no): b Page.7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:rW �� - Owner: Date of Inspection. a BUILDING SEWE R 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 of joints,venting,evidence of leakage, etc.): SEPTIC TANK: 1/(locate on site plan) nn Depth below grade: (�t/a' • 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: Sludge depth: Distance from top of sludge to bottom of outlet tee.or baffle: Scum thickness: )- 'I Distance from top of scum to top of outlet tee or baffle: . q Distance from bottom of scum to bottom of outlet tee or baffle: d! How were dimensions determined:k � rxr.�y1b/Z Comments(on pumping recommendatiions, Aet __and outlet tee or baffle condition,structural integrity, liquid levels Is ielated to outlet inve vidence of leakage,etc. XV GREASE TR��ocate on site plan}r y 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(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): , 7 Page 8 of I I OFFICIAL INSPECTION.FORM—NOT FOR.VOLIUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEM INFORMATION(continued) Property Address:Of Owner: Date of Inspectio �00 TIGHT or HOLDING TANK tank must be pumped at time of inspection)(locate on site.plan) Depth below.grade: Material of construction: concrete metal—fib ergl ass._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 last pumping: Comments(condition of alarm and float switches, etc.): DISTRIBUTION BOX (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box,etc.): PUMP 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.): 8 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: 04,x. Owner: Date of Inspect SOIL ABSORPTION SYSTEM (SAS):= /(locate on site plan,excavation not required) If SAS not located explain why: Ty P e leaching 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, CESSPOOLv�-esspool 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.): 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.): 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: , &Le- Owner: Date of AIMTO"' ti SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet. Locate where public water supply enters the building. Ran ------------- o. �ro 10 f Page 1 I of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 'Property Address: V,4 L.l r�r� , �V� LZA Owner: Date of Inspection cam, �, jUa SITE EXAM Slope Surface water Check cellar Shallow wells 1 Estimated.depth to ground water J 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: , r � " 11 3 r °� fifi l :q3 �. i Perm. Num,-er: Dare: Completed by:. f GSO.0 iC ' i.�. c; L=\/CLC.O;A VT^ ION Site Location: _ (�C u[iew �'`�G ��. _Lot N`O. . J.w�ner: L�. 1 Add.ress-- . ' ✓� ��5lY Contraclor:. address: Notes:: _ 'k w/r�_3 STEP-' 1 . . Measure dec?tb,to.-water table ., Ja_ _. to near e:.z L. I�'i.i;ti.....__......................._.-...__". _;.:..._....................._........ . /1��'DZ 1 S" Moiltfi/cry/year I STEP 2 Gone i and In.de.x Weil:-lA:a.p Iocate site anal�ecerrn ne: I (A •Appro.priate.jndex w.el'L.............._.•^_....._..............._..._....... i. .._ I• I. S:,' _°:�::. Using•month Iy.i=pof-::4•."Curreni I {_ Wet -Conditions" - I deteimine current•de;otn'to I q Wal..�• �c.ycI 7or'Indcx Wel"I . month/year II i. sT-E 4 Usine.j a ie.o -VJatar,i.emel Adjustnen.is or in� vd ex =11 (STEP 2.�\),;cument de pt h. t to wallerlevel for..i-ndex wel.l ('STEP 3•):, , 7 and•UVaier-{e`1.e7 Zone (S EP•2B) de ermine w•atar level adjust eeZt ..............._....._................._..._._......................... stirna e.ceptii o:hidh water by subt-acd-,,ie ?.ejwater- level adjustman•`.(ST•cP 4- --on mtea_.La ceptn �o water "rl�itJi•'va]u�ii�lv'vv Ti-r�ii::•�i{Vi1 Ivil•iu r 4 5 �4 Commonwealth of Massachusetts Executive Office of Environmental Affairscf Department of Environmental Protection , 19 . William F.Weld = ' a�" �;r t ') . Oowmor •f ; Trudy xe Secretaryt:o,EOEA ` f David B.Struhs - b-, Commissioner r ;_ • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 9j y PART A 4 rrs' CERTIFICATION Property Address: Q V edc-AJ jkNeVO 4 b(T_vv~ Address of Owner: ,.RR --' Date of Inspection; /—/7�b / (If different) a V eti� /`� ��f L �k Name of Inspector: v v [ DE✓ `,' Company Name, Address and Telephone Number: CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the.information reported below is true, accuratek `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 sewage disposal systems. The system: i + '�; t1 54t1 t . 4 V4. i .`:.0`3 f�?; ;. sseS 1t ' _ „ _ Conditionally Passes a .r ° Needs Further Evaluation By the Local Approving Authority ti Fails Inspector's Signature: Date: L�r> ,n The System Inspector shall submit a copy of this inspection'report to the Approving Authority within thirty(30) days of completing this W "" 4° ,''inspection`'1If the'systeni is a'shared system or has a design flow of 10,000 gpd or greater,•the inspector,and the system ownerrshall�s�ubm the report to the appropriate regional'office of,the Department of Em ironmental,Protection, r =; ,t ;,s,r, +t �, ;g Y 3f 14 �A 4•' . ,,. =w, The original should be sent w me system owner and copies sent to the buyer, if and the approving au;hon,j t y�y�E :, � }Pa�,.'S,l�=� .� i. , i ,.. .. r, • ,a i '.3, r'1 ":,## t +,:�••lk {} F..�� `��' ryft INSPECTION SUMMARY % t. ,,_ ►: a � ` r -'.i ►la>7 •tr',tiwo;: ,t'"r ; `�' ,. 'yl'f:,..l r t•!i�'i 1 { 4'r �i Check rA B C ' ;or D "y } t i3�'�--i-x; ft A �f .. c r,It ;i,r.'t in " a w# c tit.�r rl,=k,. t`4' :S < r f s'(f, ., i!-a r {,•}t w »•: .?J° I '�+ i!(i.� .i �i »�• • a € s=�AJt SYSTEM PASSES:', a ,i, �_1; .f; ,; •� { ; 1 �' ,� rl>�Qt ! a;,f' 3 . �t�3. �&.c�� ;�;w"t�# �� kti � e•., 4a :;;,i i! :d+.,4Y,i{rPs `' ' �Y, ;: ' •.. , �: . .. t 1; r r?;i rig' r=.it'i •.fib's'f'ifi' �4J'#'Y� a;,i,y a�rr idr-s+�v`.,.��ri �ti, skiV I have not found any information which indicates that the system violates any,of the failure criteria as defined to 310 CMR 15 303, Any failure criteria not evaluated are indicated below. B) SYSTEM CONDITIONALLY PASSES 4 nq,,� f , �'L� s ��t�F�#�i�y ;�'.AA+..re .r r?,� f if�f °i A�r..it� YrF , •'I .e ':`..E�,}r r:�,2... ,.r .., , ire;-ti4 y,'; •' - 5 .�%�!?' _Afr tl$ .�1 i3�tf In fy�12Ai'iry'��d"*�,#'�.�'��I��{f.r:P,H�J�. sit ie" One or more system,com orients need+to be replaced, repaired.,,;The.s stem, upon,com lesion of the replacement ogre t it t t }Y7 » �* P P P Y, P P a r r *r Ahr} passes inspection. = t Indicate yes, na, or nof:determined (Y, N;�.orND).'`.Describe basis of determination in all,instances, if.not determined ,explain why not)�A+ x _ The septic tank is metal, cracked, structurally unsound,shows substantial infiltration or ezfiltration, or tank failure is},g*�? � Yx to h ='imminentiThe's stem will sins Inspection if the existing septic tank is replaced with.a conforming-septic tank as # 4 . y Pas pe 8 P , g, PE r .# H $ A. approved k} 5 _by,the Board of Health A:y444� M . -'"b4 ��,to � �f£• . =#!revised 8/15/951 1, $�. -'One Winter Street tts. • Boston,Massachuse 02108 • FAX(617)55651049 • -Telephone(617)292 SS00ZY diet Printed on Recycled Paper .. r#a - 4a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM14 PART A -a cbtr�rt , Ms rda Yt . CERTIFICATION (continued) -W rr 1 Property Address: 1�6 CGTvY i Owner: S 0t4j�Tck,grAT Date of Inspection: BJ SYSTEM CONDITIONALLY PASSES (continued) 'rf�'`` � Sewage backup or breakout or high static water level observed in the distribution box is due to broken or:obstructed ix 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): broken pipe(s) are replaced �a; obstruction is removed k: distribution box is levelled or replaced " nA _ The system required pumping more than four times a year due to broken-or obstructed pipe(s) t.„The system will.....pa s r inspection if(with approval of the Board of Health): ' -€ I broken pipe(s) are replaced ' 8: F"k obstruction is removed +st r).•,s " ''t , . .. it•!., r t_.1a5:•, t,+�(�t'i !?;,. !. ler'h' . � r �•+�'«s a.dt�ry it7 ;•y;i „� tl; r .1'' ,. .. .. f .`: . ^ , .,.. CJ FURTHER EVALUATION IS'REQUIRED BY THE:BOARD OF HEALTH: r ',.,+ t ); ' ,Y ruy"Ii 1a Conditions exist which require further evaluation,by the Board of Health in order to determine if the systemits fading to protect the Fs public health, safety and the environment: { { ;r' 3 f. l,tt;:.ei t $ t.aF t5 diS� if uxra M� 1) SYSTEM WILL ASS U I A MANNER I P UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING = �rN � ,rut}u+K•� ' y4' WHICH WILL.PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT x» r a _ Cesspool or privy is within SO feet of a surface water ' x v r," r Cesspool orprivy is within 50 feet of a bordering vegetated.wetland or a salt marsh µt r ii, a.11�i r. . ti.s _ ,. '" !..h' 'r`°,+.i •�[; a. ,f ;., i•.. r,.:; � iry.r.r: K.t :Y ,....a. .f; it .,,...'' !f:s � tr,,�� a � .,a �g Cia�.:�•'�1i'- -#h�a �;. Y' * ti .w t\�t`t 2). ^ SYSTEM WILL FAIL'UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DET�ERf�1JNE5 THAT' THE SYSTEM IS.FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH-AND SAFETY AND THE° ` ENVIRONMENT; troy i lktr 'y ' ThP svctpm hay a.septtc tank ano soti ausorpuon system anu is within i0v feoi Li,o auidCc �atc� SupNlt or tnbwary t0 d j rt-.- 6dE• surface water supply. "$ a M-, i The system ha a s43 epyc tank and soil absorption system and is within a Zone I of a public water supply well' v l �� a ; r The system.has a septic tank and soil absorption system and is within 50 feet of a private water supply eI 11 r �{ �t�s,' f Theaysten'; has aseptic tank and soil absorption system and is less than 100 feet but 50 feet or,more ftom a riyate�wate supply well;unless a well water analysis for coliform.bacteria and volatile organic.compourids,indicates tfahe e11 ` °'� ' free from pollution from that facility.and the presence of ammonia nitrogen and nitrate nitrogen is equal to or�ess�than 5 i 3s h e{� �.fit i is att+$'`- '`.1 :i 'l..C?§ ,?��..tit }�"ft� }t..S..ile rt.:;: F tf ir:i Y!1 '.',!1# ' i�16 ';'u X$ !E �f ppm.R .. ( .at t } s s asifLf ,, L� 5 t i @„ i- •f,-card r �,!'fi >. ttfi3lt ` iu+ DJ SYSTEM FAILS: 5} ', q4� z r ` 6G`xx l:have'determmed that the system violates one or more of.the following failure criteria as defined in 310,CMRk15 303 The basis . kt'for thi;determination is identified below. "The Board.of Health should be contacted to determine what wil�be r�eessaryto correct ' �,� the failure ` z -at at�� ;�frr h 0 'a'A +y 71 �xri 'Yri ^�`Badcup of sewage into'.facility`or"system component due to an'overloaded or.,clogged SAS'or cesspools �t ft. s ¢.r { q♦ i^+ i...k, 1 Er f f rI` 1. y c '••1 �]5 `t� }° ..yq;�lp�. F�f )y .i?N',.. r r� i*•ip'.Sg A� L t „) G7•.Ot :{$ t �i�"J1 tlj)fii7l 4fl� i� Li i 5 .k.•l y.. �+&:ll:. .S.t.�r. ;it ""dl. �:.'f ji"tro) F.K?c~� . *!4 Discharge'`6.pond)ng'of effluent to the surface of the ground or,surface..waters due to an oyerloaded orclogged SAS orb " cesspool. r r 6:f Yd 4� W D :V W4 A�,Irevased 8/15/95) 2 r i k�� � . n r dXr",,a �.„.+^_..hit r�i� ..a. ,°.. ;tr3- y r "! ,,., .-.'::v.t ,�k:. t�`C>nal ,''; k .c* 1 � � v . T ..yE{}! i£`'�'v�'ty•i . f. � 'fit vF".�"r�'�s� �Y�'aR V rL J d4 YY.. r _ - 1 • Yf 'y��i d �p�iX�dy"++,!f l 'i, ,•,. :. y . 4 R ......�.1�.q,rn.. •a i r fig. h 1 t ; ,.� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 4d' {,.. PART A lit CERTIFICATION (continued) s�4x Property Address: 30 �y u'�,enJ ArK�`1E Lam' COTf�l`T Owners T to HCT ,SA-29 Date of Inspection: < D)SYSTEM FAILS(continued): ',_ ij Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool: �y Liquid depth in cesspool.is less than 6" below invert or available volume is less than 1/2 day flow. 7 . V" Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). f Number of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. ? A Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water.supply 'a . ( h �4 Any portion of a cesspool or privy is within a Zone I of.a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. .44, Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water,supply well,wit no r acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis fort cotiform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen; El LARGE SYSTEM FAILS:. ti The following criteria apply to large systems in addition to the criteria above: + • 4. The desi n.flow of system is 10,000 pd or greater (Large System) and the system is a si nificant threat to ublic.health and safet g ) g g g Y Y g p d �Y .� 'and the environment because one or more of.the following conditions exist. { 4 . p ,I xVp _ 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 p 7 the system is located in a II nitrogen sensitive area (Interim Wellhead Protection Area(IWPA) or a mapped Zone of a . public water supply well! sfhf .... kThe owner or operator of any such system shall bring the system and facility into full compliance'with the groundwater treatment program' �$ , " requirements of 31'4 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further•information � �."RINA 10 Vj;Tv iTll' $ @@}S tw .A4t�� txq`� + �'��`i'A�`tF4 a�, 7 M1 F +4I6RL ? } ' s, rx_ �tiBvi�sOd 8/15/95) 3NN, t � €: } ' ZI J,r S?' kl&i N akm C y 1 f ♦t ., ' HEST SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST ,. . x" 3 < 0 r u i T Jf Property Address: Owner: Date of Inspection: R4 Check if the following have been done: iJ # umping information was requested of the owner, occupant, and Board of Health. r l2None of the system components have been pumped for at least two weeks and the system has been.receiving,normal flow rates-g- a' during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection' /&ks built plans have been obtained and examined. Note if they are not available with N/A. , ' VThe facility°or dwelling was inspected for signs of sewage back-up. , fhe system does not receive non-sanitary or industrial waste flow ` � �/�fhe AT 10 W. site was inspected for signs of breakout. _ t LL,/All system components,-excluding the Soil Absorption System, have been located on the site. : :r t;�Ae septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition 'fit of baffles or , at, : tees, material of construction; dimensions, depth of liquid; depth of sludge, depth.of scum. f Y £ The size and location of the Soil Absorption System on the site has been determined based on existing information or. ��; approximated by non•intrusive methods, x . (/ u fa%.1 14) �.; - 'and occupants, if differe^.t from oN+ner! were provided with information on the proper maintenance�of Sub• ��� 4 Surface Disposal System. # s' i µ,t Z.. f� dt , ,+✓..Gi }Y vgi- ��fit F, 3J - `x 3s } .,';✓. ^'��' €tf ' 5C4 c . �� .„4 ,.s�"Yk*dt•rh+p'4'l.. ' n y �.vc;.._."�,�, tf''� �''R+ 'Pf' y ,pr �f 'Ytr ,�'}N� '� ii,j•1�4t � t.:� d ' i s. 7 ¢ .. ✓ �� ?�t*xt � ti� A�g{,.+r,� is �� 1 ��a Y ..e't`" ,s;'` r�.r5 31 Sx4Lt t= t `9'a fi"`{• Y'�, erg s ,w,. a^ z5, Arm➢'p��(�g` w'* }y{ 2c5 X�l R T M; Yei IS ' t( t ' t 'ham': j�'v'�k.#'�•,.i¢,j i>sr+r'', "+jw A zf. ;yV :K • } 1''lCy'fi l'°;iR-N'r°,fit ill (revised+6/15�95) 4 t t y T � �� •,t�.�'i y..� W�k�t1-',r t ,� - , - �a � d S.m�1'.' �ra-ne K; Vj'.t�y y�p,'1 '� 5 sht Y f S ]GCS Y• .. y 0 41 9t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 'f ° ✓ r PART C � } SYSTEM INFORMATION �h ,,k Property.Address:30 ( v.cery �cYhcL- L I-I fOTuiT �".Owner. lSt�IEZ-Sctiv r�•C!�-�' �. ,.. t ;Date of Inspection: + FLOW CONDITIONS ;t RESIDENTIAL: j'`'` '•-. "`. . Design flow: je'3499allons ;Number of bedrooms: Number of current residents: ��Ivum, Q ti 'Garbage grinder(yes or no): Laundry connected to system jyes or no):� `a �9 74F{`T'�' ro Seasonal use (yes or no): ,,,Water meter readings, if available: Last date of occupancy:/r ¢.COMMERCIAUINDUSTRIAL: n ,Tyoe of establishment: pesi n flow;' allons/day €�'G.re3se"trap present: (yes.or no)_ r4,Industrial Waste.Holding Tank present. (yes or no ,"�Non-samtary.waste discharged to the Title 5 system:,(yes or no)_ f 4,Watef meter'readings, if available � ,•rya�•r �.4,.., , ...<, . .: . ......�. ,. ,. . A.,Last date of occupancy. . p A�gaa F9?��$ k ,.j.,yi;Fnr f. SZ OTHER#tDescribe) x^Last date of occupanq; " fp t to ro d t1jtl,Ytp-r:rf' �x GENERAL r� fi }� fi } ��•pp 3.11f`J3�'�i,a3 { PUMPING'RECORDS and source of information: "`y�°'turf rr,a4 jh4 �1�6 (/, "l� t/� ""ii �.7 is ti bra ilia System pumped as.part of inspection: (yes or no)_ if yes;volume pumped: gallons 7131 7T t, }fir,.pump.iAn g - . A' F t k . "� dTt ji' :Yh� ' 'f`, f ! # tf 5yf t♦f1 s b45'#k`r3`orf'r Y,A�l M'v� � MS' {Reason, ; ' 1C•. iYyy ',y i )' s � TYPE O SYSTEM , Septic tanWdistribut'on box/soil absorption system # "Single cesspool � .Overflow cesspool Privy � t �l� x Shared system(yes or no) .(if yes, attach previous; spection records,,if any) ,5 �r Pik ' € u x . m *k. Other(explain) } i' '� 'r4} APPROXIMATE AGE of all.components, date, installed (if known)and source of information: r qr r �r , es Sewage odors detected when arriving at the site:.(yes or no) y : ENE lon s+(rev-ised 8/15/95I- y; "' jV s. MEN RA ,y x I r is SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART C . SYSTEM INFORMATION.(continued) Y.,, + Property Address:� t,J-ee*,! AR( -•)a L IA t W\V f � r, :% ,,Gc s c Owner: Date of Inspection: ` ,+ ,SEPTIC TANK:/ s (locate on site plan) Depth below grade:L { ,y r t «� �:.. .✓� T.t„17t ,# Material of construction: ✓oncrete _metal _FRP other(explain) i •;r ; $ Dimensions: ' Sludge depth: sr ✓ r'rt E Distance from top of sludge to bottom of outlet tee or,baffle: { , ,i Scum.thickness:�_ fir► ti 3, Distance from top of scum to top of Out tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: ' V i FI�Y.I.�°`•f`W,;ems �r Comments: i (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet�mvert�}structural hi :integrity, evidence of leakage, etc.) �.,,,,,;.Z1 i y gA77;'4b�y ' TF 4v x €41 +: r 7 GREASE TRAP...!? r f� Ar . M r , uy a;(locate on site plan) .�. atia Depth below grade: �,nt n = Material of construction: _concrete metal _FRP._other(explain) �z r r fzt Dimensions: ` Scum thickness: 3x,<i,,�a•)'� t�-3 zl��.tfl ¥ �` � .- Distance-from top of scum to top of outlet tee or,baffle: 2, C�i�tance from bottpm �� ���� �^bntjorr. of otltlet tee M battle' 1 , #,, rv; K + ' r'F AS 0 . t �l�s Ufa `' T 3yA t 9s Comments s •� r ' recommendation for um m , condition of inlet and outlet tees or baffles;•depth of liquid level in relation to outlet inverttstructural { ak�ntegrity, evidence of,leakage,•etc.) Op1G A,a 'sue' k;4i�a„1,g 4At1 ..+s✓lei yy rc'+4 hf , !,✓ i .:ta '..r fi x -!!,, +Ii Y 44` �, 4(111�}WWi dA4'{ .l'' .w+'... royq FW{teh4l.µ, � YH ,• . Ja_. f 4 HW.T,F44/•.-;t,�,��.si`kt ��� '• �` NMI �}+�•#t'.•�. � "`. .,.,:. r:a...•re ..� •�..».«. .a. ,... r�. uw.. �...v_ i74 # qi`,S. i.; -`�T , te 61 Jl,:}':, q :.;'< at{, r gp` sp'a ..+r,_ .,.0 �eo-y ,y,•c. j. e_iTt�7ii4, >''a"? ;.,,• r t ' -.urt. I+ �I�i u"`9 �ifid i'�"CS$it'°etti"t 4k. �t '+StY t y ;Fy}. §}y t 4 qt�`ys 'k 1 14 1 9t '�*�i� ,{- ���t�sn�s� � �. � •° �. �w .3Ei +,� ,t:'.9� j� t1?,r$+ s�ai�a�fla`t,T�tl�� �F #�'�� rsrE�r„ � (r6vised n SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART C SYSTEM INFORMATION (continued) Property Address: (Sk.V-arax%_d140- U-tom lM'. GbZil( i .K , ;ttah Owner: _'pw(lam' b y":. 4.r i�1s4's&�fyyt��a Date of Inspection: ss a37 'Ami as ral .i3 fd J strTIGHT OR HOLDING TANK:_ i .. r a , yb 'tt+(locate on site plan) 4 ',i iu' } vt�. � r' Depth.below.grade: p<, . f.',j . construction: concrete _FRP other(explain) Material.of constru. . . 3 r � "2 Dimensions: Mr, 4 Capacit�i gallons t "Design floes: gallons/day eY,�,Alarm level. "4 Comments: , ,.Y; (condition,of„inlet tee-condition of,alarm and float switches,.etc.) MW jx D ",.' IBUTION BOX: ic `, Ax.SrrNitno- �.w�+1 (����EP b�•ln�. ,,.`,i�' (locate on.site plan) $�,ik Depth of liquid level,above outlet invert: ar j Comments: ��'`,ztnote ii levei and distrilwt w. ,,ryua�, e1'dence of sukd 'ca;r)otier, evidence of leakage into or out of,boR,, etc) 4 a t. lY AVr un � #i t 1 F, ° r�r �. YPp, tics �-'F%��' PUMP.CHAMBER .11 v t `Slocate on site.plan)17 Vie ixPumps m wor order(yes or no) ' $a { Comments * rl ' 1 � : _4,S,(note condition of pump chamber, condition of pumps and appurtenances, etc.). t�r�j..a,p�r ytrw, rsgFa '� 'prN�"+•P1,.. ,.6a,m y..w +, va i .va... .. VW, wr lY WL V. . e t3 + � 4lrevaaed�8/16/95). . 7,`. X, Ws"6* k t f >f..+.e ♦ J SU BSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART SYSTEM INFORMATION (continued) Property Address: Owner: �jh1"�:r < �•�._ Date of Inspection: SOIL ABSORPTION SYSTEM (SAS) not required, but may be approximated by non-intrusive methods) (locate on site plan, if possible; excavation If not determined to be present, explain: Type: ' leaching pits, number: leaching chambers, number:-- leaching galleries, number: r leaching len 'n trenches, number g the g leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level✓f ponding, condition of vegetation,etc.)_ ' ,sl s n i CESSPOOLS: -64 (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 gruundv.alc;. 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) Dimensions: Materials of construction: Depth of solids:,___ Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) 8 (revised 8/15/95) i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:_3O QV erV J4ttNh LNG Owner: �..� ` Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: `A'• include ties to at least two permanent references landmarks or benchmarks .; . locate all"wells within 100' '2 Z A. Y � . 1 � f f i l Q} � ✓r �, r � `shy '�,? fi�'�, f , Ny Kra tom{.,Aryt'si t¢i+ �I des, >>Cr j+ - sf.2r 'k vX �'S'•� x`Der1 TO GROUNDWATER a to pf NO WAFT/ r rXy � q Depth to groundwater: j�' feet method fdetermination.or approximation:01 ,t Ell W ffiv S h (revised 6/15/951-: 9 Z ` _014 gb y a i� �'�"y �,�� �Kr�t`« 'c� j d�' .t° 4.; + t•<. � ' � kE.yi r�"7�w a�°r �, �,�i:lr'�Yn, EL.FNDN, AT 40.8 PROVIDE IF NECESSARY SYSTEM PROFILE TEST HOLE LOGS ACCESS COVER TO WITHIN 6" OF FIN. GRADE (NOT TO SCALE) ACCESS COVER (WATERTIGHT) TO ENGINEER: p'A' OJALA, SE M MINIMUM .75' OF COVER OVER PRECAST WITHIN 6" OF FIN. GRADE 2% SLOPE REQUIRED OVER SYSTEM 40.0' 41 .0' WITNESS: DAVIQ STANTON sT 2" DOUBLE WASHED PEASTONE DATE: 12/18/02 I EL. 37.5' RUN PIPE LEVEL FOR FIRST 2' < 2 MIN/INCH PERC. RATE EXISTING 1000 GALLON SEPTIC 36.44' I 10395 a� CLASS SOILS P# ra TANK (H- 10 ) GAS © C3 M M � L� ml_[� LOCUS a� (RE-USE) BAFFLE994 � 45.39, 35.56 35.24 C1OC] C� © C� C� fJQ 4 / �� m CI O m m m ED = C7 ELEV. �° ✓ 6" CRUSHED STONE OR MECHANICAL $ �5 �� p ' CO CI 0 0 ED C7 0 C1 C7 0 0" Q t'`' COMPACTION. (15.221 [21) $$ 2 a 33.24 DEPTH Of FLOW 4 ( 1 % SLOPE) ( 1 % SLOPE) 3/4" TO 1 1/2" DOUBLE WASHED STONE FILL �qr TEE SIZES: 10" A F INLET DEPTH 10„ OUTLET DEPTH 1` LS LOCATION MAP NTS A• 14" 10YR 3/2 FOUNDATION--- EXIST. SEPTIC TANK 54' D' BOX 17' LEACHING FACILITY 1 2' * B ASSESSORS MAP 22 PARCEL 121 + 4$.7 21't LS *** CONFIRM SEPTIC TANK OUTLET INVERT PRIOR TO $ INSTALLATION OF ANY PORTION OF SYSTEM j/ 36 10YR 6/8 39. ' -�- + 48,8 / �6 C BOTTOM TH 1 EL. 32:0' perc G-W ELEV. APPROX. 12.0' MED COS PROP. VENT (FINAL PLACEMENT WITH HOMEOWNER CONSULTATION) *CONFIRM SUITABLE so FOR a' BENCH MARK CORNER OF 2.5Y 7 4 BULK HEAD. ELEV. , + A � 40 6 8 INSTALLING C Y I L NG ANY PORTION OF SEPTIC / as�� ,�� 4,0 SYSTEM 1�� 42 % ,0 120" 32.0' + 49.1 , rk6 / + 4 .8 1 NO WATER ENCOUNTERED TH NOTES: + bp.2 SEPTIC DESIGN: (GARBAGE DISPOSER IS NOT ALLOWED ) + 43,&--"' 1 sr. APPROXIMATED FROM QUAD MAP 40.1 DESIGN FLOW: _ BEDROOMS ( 110 GPD) = 330 GPD 1 . DATUM IS US A ��J C;�� DESIGN F'L W 2. MUNICIPAL WATEM IS FXISTING - a9 © aa2 �� SEPTIC TANK: 330 GPD ( 2 ) = 660 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT.4.3 E DESIGN LOADING FOR ALL PRECAST UNITS TO BE AASHO H_ 10 T. 5T 'I USE A 1000 GALLON SEPTIC TANK (RE-USE EXISTING) 44 XISXIS USE) GARAGE --- 5. PIPE JOINTS TO BE MADE WATERTIGHT. (RE + 40.3 / LEACHING: 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH MASS. + 40.3 <o��� / \ �6 SIDES: 2(30 + 9.83) 2 (.74) - 118 ENVIRONMENTAL CODE TITLE V. 40.6 40.8 // �,� ,�5 30 x 9.83 (.74) _ 218 7, THIS PLAN IS FOR PROPOSED SEPTIC SYSTEM ONLY AND IS NOT 0 PAVED 35.9 BOTTOM: TO BE USED FOR ANY OTHER PURPOSE. DRIVE 454 336 S. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC. � + 40.1 E � TOTAL: �. S.F. GPD .1 E USE (2) 500 GAL. LEACHING CHAMBERS (ACME OR 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED WITHOUT i EXIST. a0.1 'k 7.3U INSPECTION BY BOARD OF HEALTH AND PERMISSION OBTAINED tk+ $ +< �DE�CK DWELL. \ r;lfC (APPRO oNLY)* d33.7 EQUAL) WITH 2.5' STONE AT SIDES, 4' AT ENDS AND 5' FROM BOARD OF HEALTH, TF = 40.8' BETWEEN UNITS to / 10. PUMP & REMOVE (OR FILL W/CLEAN SAND) FAILED LEACH PIT P� �33.7 + 3 .731.C� oK LOT 90 1.9 /31.2 20,513t SQ. F 39.6 39. ✓, 31.2 LEGEND + X41 TITLE 5 SITE PLAN �` GP W "�� ✓ 30.6 / 100.0 PROPOSED SPOT ELEVATION OF 39.6 S "NOT MARKED OUT AT TIME C'f 0 QUEEN A N N E ROAD PERC OD �� 9.1 �� y`L/ _�02 100x0 EXISTING SPOT ELEVATION N / �� /�� / ✓/ IN THE TOWN OF:a 39.3 �`� / 100 0 PROPOSED CONTOUR (COTUIT) BARN STABLE 39.2 0 / 30.7 100 EXISTING CONTOUR PREPARED FOR: gORTOLOTTI CONSTRUCTION/LADD 38.8 20 0 0 20 40 6D BOARD OF HEALTH D + .5 APPROVED DATE MA SCALE: 1„ _ 20' DATE: DECEMBER 18, 2002 3 .2 ,G 39.0 c� ✓ D / / �O4 off 508-362-4541 3 / fox 508 362-9880 ��t �ytl-y'i Syr" i down cape engineerng, inc, H Of�� o ARNE Uj �4 ARNE H. H. CIVIL._ ENGINEERS V a OJALA r � 'aJAI�, y CIVIL .26' 35.4 LAND SURVEYORS N . 30i92 AFC 939 vain st. yarmouth, rya 02675 sr �-or 42- 389 .18, 0JALAI 4, AL.S. VANE