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HomeMy WebLinkAbout0068 SCREECHAM WAY - Health 68 Screecham Way, Cotuit —" A= 022. 133 t ;I . CJ TO OF BARNSTABLE LOCATION SCe ��� SEWAGE VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY ' Ira e-,11 6vi LEACHING FACILITY: (type) 5410 Gz L 1,,.e4 C"k j (size)/2:S®'/-A5 'e� NO.OF BEDROO S BUILDER O OWNE PERMTTDATE: /Z -=fT COMPLIANCE DATE: 11 LCo 9 ) Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility r� 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 ..� �a �. d'� � �31 �, � ��� . ��� O y . ., 0 Z2--X,t33 No. Fee A THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 01pprication for Migotal *p!5tem Con!5truction Permit Application for a Permit to Construct( )Repair( )Upgrade(�1)Abandon( ) O Complete System 2JIndividual Components Location Address or Lot No jB� ,�„ w A1.2 Owner's ame,Address and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 771J: Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow .3 P gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. L '3 70 Description of Soil � GCG Chl�l�+b�l�J /Z•S�ZS�X� Nature of Repairs or Alterations(Answer when applicable) 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 b this and f Healtl Signed_T� Date Application Approved by Date/a.—_1 Application Disapproved for the Yllowi,ng reasons Permit No. Date Issued No. Fee �2 0 / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: k `-Yes s PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZIppYication for Migoga[ *pgtem Congtruction Permit Application for a Permit to Construct( )Repair( )Upgrade(N)Abandon( ) ❑Complete System ?/Individual Components Location Address or Lot No./� �L�G Owner'syame,Address and Tel.No. �J y AlnlleO GPr1;4 'i%1 Assessor's Map/Parcel G07'`a 7` Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. -7 7/,.! Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder Other Type of Building eNo.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow l/C� gallons per day. Calculated daily flow J✓9 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. ` $lOOg0�Of7 Description of Soil /Z.✓4, Nature of Repairs or Alterations(Answer when applicable) /'�/� ��. �� 7&Le, l�9 f Date last inspected: ". Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued bb this and f Health. Signed /��� Date /Zb 7 Application Approved by Date /a -___1j' Application Disapproved for the Yllowl,ng reasons 1 r� Permit No. - Date Issued ----------------------------------- -- i THE COMMONWEALTH OF MASSACHUSETTS a —133 BARNSTABLE, MASSACHUSETTS yj Certificate of Compliance-',-' � THIS IS TO CERTIFY, that the On-site Sewage Disposal System Conktructed( Repaired( VUpgraded( )_ Abandoned( )by �fUGri � 4, t at gw We Cd 7` 17� +:.� �' ` _ has�be �,~\ en constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 917 '5 dated Installer Designer_ The issuance of this permit shall not be construed as a guarantee that the system will,functiop(As desig$�e��. Date 1� -7 Inspector cz� _ cr0 s� y ` q No.__ (0 / � aZ Z/33 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS lwigpogar *pgtem Congtruction Permit Permission is hereby granted to Construct(// )Repair( Upgrade(' )Abandon( ) System located at b 4- GO 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 this permit. d by Date: Approve l .. A j �;;.r"s•�t,� � �CQ� <S cat-��u.4� ��-( P05 .y. eI 10/9/97 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT ENGINEERED PLANS) hereby certify that the application for disposal works- construction permit signed by me dated ` -X? 7 , concerning the property located at meets all of the following criteria: /There are no wetlands located within 100 feet of the proposed leaching facility V There are no private wells within 150 feet of the proposed septic system r There is no increase in flow and/or change in use proposed /There are no variances requested or needed. ✓ if the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the . proposed leaching facility will=be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation. Please complete the following: A)Top of Ground Elevation(according to the Engineering Division G.I.S.map) B)Observed Groundwater Table Elevation(according to Health Division well map)1Z'?' G� SIGNED: DATE: LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER Ian of the proposed system.Also if the licensed installer posesses a certified plot plan, [Attach a sketch p p p y this plan should be submitted]. q:health folder:cert V 1 TOWN OF BARNSTABLE !AI.? SEWAGE # 7-� g LOCATION f© !L T ASSESSOR'S MAP & :VILLAGELOT ' :.INSTALLER'S NAME&PHONE N0. `.SEPTIC TANK CAPACITY �fo o G 'vy aL 19 S"��5- G (size) IEACHING FACILITY: (type)) S �• .•• •�' ) N6..6F BEDROO S r B;UII:DER O OWNE r� ERMIT DATE: Z T COMPLIANCE DATE: 1� Sepaadon Distance Between the: S-� Feet Ivaximum Adjusted Groundwater Table and Bottom of Leaching Facility :Private Water Supply Well and Leaching Facility (If any wells exist Feet site or within 200 feet of leaching facility) ::Edge of Wetland and Leaching Facility(If any wetlands exist Feet 'within 300 feet of leaching facility) `?P6rnished by __--_ -.---- 110�v :1. 0 { I i .. �1Ne Town of Barnstable Department of Health, Safety, and Environmental Services r • Public Health Division � L►RNg!'ABLE. 367 Main Street, Hyannis MA 02601 ' QED MIS� Office: 508-790-6265 Thomas A. McKean, RS,.CHO FAX. 508-790-6304 Director of Public Health Mr. Cartmill December 2, 1997 68 Screecham Way Cotuit, MA ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL CODE, TITLE 5. The septic system owned by you located at 68 Screesham Way, Cotuit was inspected on November 12, 1997, by John Graci, a Massachusetts licensed septic inspector. The inspection of your septic system showed that your system has failed under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • The soil absorption system was in hydraulic failure. • The leaching pit was "past the effective depth of leaching." You are directed to hire a licensed Town of Barnstable septic system installer to submit a sketch diagram of a proposed system to the Town of Barnstable Health Division Office (Town Hall, 367 Main Street, Hyannis) that will bring the septic system into compliance with 310 CMR 15.00, The State Environmental Code, Title 5 within(14) fourteen days of receipt of this notice. You are also directed to bring the septic system into compliance within thirty(30) days of receipt of this order letter. You are further directed to maintain the system by hiring a licensed septage hauler to pump the septic system to prevent discharge of sewage or effluent into the buildings, onto the surface of the ground, or in to surface waters. Any person aggrieved by any order issued by the local approval authority may appeal to any court of competent jurisdiction as provided for by the laws of the Commonwealth. PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean, R.S., C.H.O. Agent of the Board of Health 4 Town of Barnstable • Department of Health, Safety, and Environmental Services 9'"M%SSB t Public Health Division s6J9. FOB 367 Main Street, Hyannis MA 02601 Office: 508-790-6265 Thomas A.McKean,RS,CHO FAX: 508-790-6304 Director of Public Health TO: i ..l 14- �ciV l l.� re CIn' DATE: - Z cC2 WA- ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL CODE, TITLE 5. The septic system owned by you located at(pg was inspectedN on by Goa(-, , a Massachusetts licensed septic inspector. The inspection of your septic system showed that your system has failed under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: � • ��Sdr ,91 tea ;n cod' Q QCP You are directed to hire a licensed Town of Barnstable septic system installer to submit a sketch diagram of a proposed system to the Town of Barnstable Health Division Office (Town Hall, 367 Main Street, Hyannis) that will bring the septic system into compliance with 310 CMR 15.00, The State Environmental Code, Title 5 within (14) fourteen days of receipt of this notice. You are also directed to bring the septic system into compliance within thirty, (30) days of receipt of this order letter. You are further directed to maintain the system by hiring a licensed septage hauler to pump the septic system to prevent discharge of sewage or effluent into the buildings, onto the surface of the ground, or in to surface waters. Any person aggrieved by any order issued by the local approval authority may appeal to any court of competent jurisdiction as provided for by the laws of the Commonwealth. PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean, R.S., C.H.O. Agent of the Board of Health q%Wth�1eV7tldidx iL — Commonwealth of Massachusetts Executive Office of Environmental Affairs Dept. of Environmental Protection John Grad One winter Street,Boston,Ma. 02108 D.E.P. Title V Septic Inspector P.O. Box 2119 Teaticket,MA 02536 : 02 2, 13 3 . (508)564-6813 WILLIAM F.WELD Governor ARGEO PAUL CELLUCCI Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION �r ,V�✓ 1 C TOy�✓OFggg 8 199. _- Property Address: 68$creecham Way Cotuit Address of Owner: �(TyD PjTgg�F Date of Inspection: 11112197 (If different) Name of Inspector: John Graci Cartmill I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000) Company Name,Address and Telephone Number: s CERTIFICATION STATEMENT information reported below is true, accurate I certify that I have personally inspected the sewage disposal system at this address and that the I re P 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: This Inspection Is based on criteria defined In TRIe v _ Passes code310CMR16.303.My findings are ofhowthe system is _ COnditl0 Ily asses performing at the time of the inspection.My inspection does _ septic system end any of its components useful life.ranty or guarantee ofthe of the Needs rth Evaluation By the Local Approving Authority not Imply any x Fails Inspector's Signature: Date: 11112197 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. 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 defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,passes inspection. Indicate yes,no,or not determined(Y, N, or ND). Describe basis Hof 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 04127197) One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: sa screecham way Cotuit Owner: Cartmill Date of Inspection:11112197 Sew.aQe backup or.hreakout.or. hiah.static water level observed.in.the distrihution box is due to a broken, or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if (with a . Describe observations: approval of the Board of Health). broken pipe(s)are replaced obstruction is removed distribution box is leveled 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 PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: — The system has a septic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a surface water supply. — The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply well. — The system has a septic tank and soil absorption system and 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 presense of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method usedto determine distance (approximation not valid) 3)Other � D] SYSTEM FAILS: You must indicate either"Yes"or"No"•as to each of the following: x 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 No -X— Backup of sewage in facility or system component due to an overloaded or clogged SAS or cesspool. x_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged cesspool. x_ _ SAS is in hydraulic failure. (revised 0427197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: esScreechamWayCotuit Owner: cartmill Date of Inspection:11112197 D]SYSTEM FAILS(continued) Yes No X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Numbers of times pumped x Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. — —X. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. — X Any portion of a cesspool or privy is within a Zone 1 of a public well. — —X. Any portion of a cesspool or privy is within 50 feet of a private water supply well. X 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: 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 — x the system is within 400 feet of a surface drinking water supply — x the system is within 200 feet of a tributary to a surface drinking water supply — x 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 bring 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 04127197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: os screecham Way Cotuit Owner: Cartmiil Date of Inspection:11112197 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: _c_ — Pumping information was requested of the owner, occupant,and Board of Health. x None of the system components have been pumped for at least two weeks and the 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. x As built plans have been obtained and examined. Note if they are not available with N/A. x — The facility or dwelling was inspected for signs of sewage back-up. x — The system does not receive non-sanitary or industrial waste flow. -x— — The site was inspected for signs of breakout. x _ All system components, excluding the Soil Absorption System, have been located on the site. x 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.. x — 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 Systens. x Existing information. Ex. Plan at B.O.H. x Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is — — unacceptable)[15.302(3)(b)] (revised WNW) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 68 screecham Way cotun Owner: cartmiii Date of Inspection:W12197 FLOW CONDITIONS RESIDENTIAL: Design flow: 330 g•p•d./bedroom for S.A.S. Number of bedrooms: 3 Number of current residents: 4 Garbage grinder(yes or no): Yes Laundry connected to system(yes or no): Yes Seasonal use(yes or no): No Water meter readings, if available:(last two(2)year usage(gpd): nra Sump Pump(yes or no): No Last date of occupancy: nla COMMERCIAL/INDUSTRIAL: Type of establishment: nia Design flow:0 gallons/day Grease trap present: (yes or no) No Industrial Waste Holding Tank present:(yes or no) No Non-sanitary waste discharged to the Title 5 system:(yes or no) No Water meter readings, if available: nra Last date of occupancy: nra OTHER:(Describe) nla Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System was last pumped 4 months ago. System pumped as part of inspection: (yes or no)No If yes,volume pumped:0 gallons Reason for pumping: nla TYPE OF SYSTEM x Septic tank/distribution box/soil absorptions 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 information: 1981 Sewage odors detected when arriving at the site: (yes or no) No (revised 04127197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) C Property Address. 68 Screecham way otuit Owner: cartmill Date of Inspection:11112/97 SEPTIC TANK: x (locate on site plan) Depth below grade: ts" Material of construction:x concreate metal FRP Polyethylene_other(explaln) If tank is metal, list age o . Is age confirmed by Certificate of Compliance No (Yes/No) Dimensions: t.e'6"h5'7"w4'10" _ Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: 26" Scum thickness:3" Distance from top of scum to top of outlet tee or baffle:over Distance form bottom of scum to bottom of outlet tee or baffle:0 How dimensions were determined: Measured Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) Septic tank and all components are structurally sound.Recommend pumping system every two years for maintenance. GREASE TRAP:_ (locate on site plan) Depth below grade: rda Material of construction: concrete metal FRP Polyethylene_other(explain) Dimensions: rda Scum thickness:rda Distance from top of scum to top of outlet tee or baffle.rda Distance from bottom of scum to bottom of outlet tee or baffle: rda Date of last pumpingr a Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) nra BUILDING SEWER: (Locate on site plan) Depth below grade: 2' Material of construction:_cast iron x 40 PVC_other(explain) Distance from private water supply well or suction lineP- Diameter: 4" Qmments: (conditions of joints,venting,evidence of leakage, etc.) (revised 04127197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Bs Screecham Way Cotuit Owner: Cartmill Date of Inspection:11112/97 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: nra Material of construction:_concrete_metal_FRP_Polyethylene_other(explain) Dimensions: nra Capacity: rda gallons Design flow: nfa gallons/day Alarm level:_nra Alarm in working order?_Yes_No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) nra DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: nla Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box etc.) nra PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no)No Alarms in working order(yes or no)_ye: Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) nra (revised 04127197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 58 Screecham way cotuit Owner: Car mill Date of Inspection:1111112197 SOIL ABSORPTION SYSTEM (SAS):x . (locate on site plan, if possible;excavation not required, but may be approximated by non-intrusive methods) If not determined to be present,explain: nfa Type: leaching pits, number: 1_000 gallon leach pit leaching chambers, number:We leaching galleries, number: nia leaching trenches, number, length: nfa leaching fields, number, dimensions:nia overflow cesspool, number:nia Alternate system: nia Name of Technology:_nfa Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) The leach pit Is past the effective depth of leaching.The sea is in hydraulic railure.PR was ponding. - - CESSPOOLS: (locate on site plan) Number and configuration: nia Depth-top of liquid to inlet invert: nia Depth of solids layer: nia Depth of scum layer: nfa Dimensions of cesspool: nia Materials of construction: rda Indication of groundwater: nia inflow(cesspool must be pumped as part of inspection) nfa Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) nfa PRIVY:_ (locate on site plan) Materials of construction: nia Dimensions: nia Depth of solids: nfa Comments: (note condition of soil, signs of hydraulic failure, level of iponding, condition of vegetation, etc.) nra (revised 04127197) i . , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 68 Screecham Way Cotult Cartmill 11/12197 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) � e p d AA `�� c At (,b qig (revlsed00)27197) Pay 4 of 20 ` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM . PART C SYSTEM INFORMATION(continued) 68 Screecham Way Cotult Cartmill 11112197 Depth of groundwater 12. 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 x Use USGS Data Describe in your own words how you established the High Groundwater Elevation.(MUST be completed) USGS Maps and Charts (revised0427197) Pape 10 of 10 • as • No:,....� Fxs.-..!3°....�-.._ THE COMMONWEALTH OF MASSACHUSETTS X BOAR® OF HEALT .......... -----d .....OF.............�.L G ..- ...... Appliration for Disposal Works Tomarurtion Vamit Application is hereby made for a Permit to Construct (`e) or Repair ( ) an Individual Sewage Disposal System at:� ®� � 0.;../ ------ ------•- . --- --........................................... ................ r o .---•... - - ------o N . .. ©s.----- . . .............. .......................... - O 0. .a-------------#.... ............. O .. .... .. nstaller Address Q Type of Building Size Lot_-_. ._ __.. ...Sq. feet Y�2S Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder 14 _ `4 Other—T e of Building No. of persons............................ Showers — Cafeteria Q' Other fi res ...................................................... W Design Flow............................................gallons per person per day. Total daily flow............3..__.........__._.........gallons. WSeptic Tank—Liquid capacity./$w.gallons Length................ Width................ Diameter................ Depth.-__-_------._. x Disposal Trench—No..................... Width--------------------- Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.........I.......... Diameter.................... Depth below inlet....._.............. Total leaching area------------------sq. ft. Z Other Distribution box (X) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date---------------------------------------- Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water-_._______-___--_-.__--. f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water________________-___---. ►x ----------- -----------------------------------------------------------•---•----------•-------•......................................................... 0. Description of Soil----------- ..s......................................................................................................................................... U ---------------------•-----------------------------------------._......._..........-----------------------------------------------------------------------•-•-------------------------------...-------- W ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 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 Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been iss ed by e boar Valt Signed -•--------------------------------- ------- Date ApplicationApproved BY------.. ' 1�-------------------------------•--•-----•-••--------------•................. ------------------- -- Date Application Disapproved for the following reasons--------------------------------------------------------•-----------------------------------•---•---------------- -- -- ------.-. ------------------------------------------••••••-------------•---•----------------------------------------------------------------------------------------------- ------ Date Permit No..... "......---•-•---------------------•----- Issued...... ..................6 / ...........--•----------- Date ��— ---'"""'- No.`_------ =;.3•;k--•- ° Fps....... �..... THE COMMONWEALTH OF MASSACHUSETTS x X BOARD OF HEALTH /......L/L %t -._.OF............../-�J GL t�G�C�3 L............. Appliratiuit for Diopuottf Nurks (futiutrurtiutt "rxotit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: ' Lo'cation-'Address or Lot No. ff )) Owner Address 4Installer Address QType of Building Size Lot.... /... .......Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder (i') Y& pa Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other.fP$'ures ...................................................... ------------------------------------ W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons. WSeptic Tank—Liquid capacity.f�:�.�..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 ( ) a Percolation Test Results Performed by..........................................................---------•----. Date--------------------------------------- Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ Test Pit No.-2;."...........minutes per inch Depth of Test Pit.................... Depth'-td"ground water........................ ;S ----------------------•----------------------------------------------------------•------•----•------------------•-------------------------- Descriptionof Soil...............................4..........•--••-•........--•••---•-•-••-•-•--••-•---•-•-•-•-••-•-•-••-------•------•-------------------------------------.------- -•-••------••-•------••••-•---------- ..............................--••--•--•--•-••-•••--••••---•••--••••--••--•••----------•--•-•-•---•-••••-•----••••----------•-•---•--•---•-----.........-------- W ............................................................................................................................................................................. .......................... U Nature of Repairs or Alterations—Answer when applicable-----------------------------------------------------------------------------------------------. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with r the provisions of Article`XI Hof the State Sanitary Code—The undersigned further agrees not to place the system in operation until a CertificateVof Compliance has been issued by the board-of health. Signed.........................................................-----•-----------•-•--•------ -------------------------------- Date ApplicationApproved By....... -;-- ---•------•-----------------------•-------•------------•-•--•------------ -•------------------Da--e--------------- Dat Application Disapproved for he following reasons---------- -------------•-----------------------------------------------------------------------=----------.----- ...------•------••---••-•------------------------••.-----...------------------------------...........---------••----•--•------••-•----------•-•--•----•---•------------•------------- ................ Date Permit No. -....-.. Issued---./f1_- �' ..------------------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH F., wise.../..............O F.......: .ff�! ✓..t. a�d t:........................................... re Tatif iratr of Toutpliatirr „ THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ) or Repaired ( ) by-------------------• ------•-- ' ................ ......•---...Installer .... .---•-•. cr`c�r at ,blurt h .... ----- has been installed in accordance with the-Construction provisions of Article XI of The State Sanitary ,�C de �s s err�'ed in the �x-� application for Disposal Works onstruction Permit� ...................... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATI F A TORY. ` .. DATE.................................... 11 . .... � , �� Inspector �i .0 " THE COMMONWEALTH, OF MASSACHUSETTS BOARD OF',HF�LTH 7'G cG,c 45j.Ie�J le,.. . ..........................................OF..................................................................................... No......................... FEE........................ � x�� (nutt��ritt#iutt rant# Permissio is hereby granted.............................................................. -••---•-••--------.....----......••--••----------•---••••............•-•---••. to Construct ` ) or op?�r,�_ ) a.Wjn4ieij0ual SewFe Disposal System at No •...............•----------:---......-•--------....._......... ._..'::. ",,"Street as showl on,the application for Disposal Works Construction Permit No `...__.... -- -. -•-- Dated--------------••----...................... ��j��. m +, DATE.-� =------ ---------------------------�-- ._ -�� Board of Health u� FORM .1255. .HOBBS & WARREN. INC.. PUBLISHERS -. 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