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HomeMy WebLinkAbout0141 SHELL LANE - Health 141SHELL LANE_,;COTUIT 019,129 i i t TOWN OF.BARNSTABLE LOCATION l`W .SA' /1.'"X,41V t SEWAGE # I Aw - ^`-:. ASSESSORS MAP & LOTS"`•. INSTALLER'S.NAME&PHONE.NO. j SEPTIC TANK CAPACITY I D®O 9� �' /"X . _r LEACHING FACILITY: )(size `~ NO.OF BEDROOMS BUILDER OR O (EIV- 1 �� PERMTTDATE: = COMPLIANCE DATE: Separation Distance-Between 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 fee f Vacl 'UWfaci ' ) Feet Furnished bAck of IA095f l V DATE: 10/.1.9./98 PROPERTY ADDRESS:141 S-iveil Lane CotuityMass. 02635 On the above date, I Inspected the septic system at the above address. This system consists of the following: 1 . 1 -1000 gallon septic tank. 2 . 1 -1000 gallon •precast leaching pit. 3 . 1 -Distribution box. Based bn my Insr-actlon, I certify the following conditions: 4 . This is"a title five septic -system.,-(- .8. Code ) ' 5 . The septic system is in proper working order at -the present time. 6 . This is a three bedroom house with a loft: SIGNATURE: Name J P Macomber Jr_ i : . . - - ------- Company:_J• P_Macocgber & Son•_Inc , Address ' Cente�rvi11e A sj. _02b32 Phone: ' ___50$..1.7_�3338_______ •. I THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY JOSEPH P. MAC4MBER & SON, INC, Tanks,-Ceupoo1YLaach(leld: Pump+d L Instilled Town Sewer Connections P.O. Box 66' Centerville, MA 02632.0066 77.5-33U 775-6412 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON, MA 02108 617.292-$500 WILLIAM F.VELD TRUDY COX Govcmor Sccrcu ARGEO PAUL CELLUCCI DAVID B.STRUt Lt.Govcmor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commission PART A CERTIFICATION Property Address: 141 Shell Lane COtuit,Mass. Address of Owner^ S 9 Date of Inspection: 1 0/1 9/9 8 (If differenU Name of Inspector: 70g.,h 12 44a4�Qmber Jr. �® I am a DEP approv system inspector pursuant to Section 15.340 of Title 5 0 CMRR 15.#t d� Company Name: J.P.Macomber & Son Inc. `( �4 Mailing Address: Box 66 C n ryi 1 1 P.,MasG__ 02632 T 2 Pe© Telephone Number: r�—u r;_Z 3 313 2 in o,� 19g98 � CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and t at the inform�Qt ned is true, accurate and complete as of the time of inspection. The inspection was performed based on my tra trtg,and experience in th�e3p oper function and maintenance of on-site sewage disposal systems. The system: Passes _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: / Date: The System Inspector . all submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: AI SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: Bl SYSTEM CONDITIONALLY PASSES: One or more system components as described in the 'Conditional Pass' section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If`not determined', explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of 's 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 exhitration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04/25/07) Dap• 1 of 10 DEP on the World Wde Web: http:/twww.magnet.state.ma.us/dep Printed on RecyGed Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) ± PropertyAdd(ess: 141 Shell Lane Cotuit,Mass. . Owner: Patricia Jones, pate of Inspection: 1 0/1 9/9 8 . B) SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed In the distribution box is due to broken or obstructed pipe(s) or due to a broken, stnled or uneven distribution box, The system will pass inspection if(with approval of the Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box Is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pus inspection If(with approval of the Board of Health): broken pipt(s) are replaced obstruction is removed C) FURTHER EVALUATION IS REQUIRED BY THE BOARD Of HEALTH: Ub 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, safery 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 ENVIRONMENTi Cesspool or privy is within SO feet of a surface water (YU Cesspool or privy is within 50 feet of a bordering vegetated wetland or a $all marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THA' THE SYSTEM 15 FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY MD THE ENVIRONMENT: db The system has a septet tank and soabsorption it sy stem (S.4S) and the SAS is within 100 feet to a surface water supply of tributary to a surfact watt( supply. The system has a optic lank and soil absorption system and the SAS Is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS Is within SO feet of a private watt( supply well. LI) The system has a septic tank and soil absorption system and the SAS is less than 100 fete but SO feet or more from a private water supply well, unless a well water analysis for eollfo(m bacteria and volatile organic compounds indiotes that the well is free from pollution from that facility and the pretence of ammonia nitrogen and nitrate nitrogen is equal to or less than S ppm. Method used to determine distance j44 (approximation not valid). 3) OTHER (r•vi••d 0�/73/s7) Ia0. 3 or 30 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Properly Address: 141 Shell Lane Cotuit,Mass. Owner, Patricia Jones Date of Inspection: 1 0/1 9/9 8 D) SYSTEM FAILS: You must indicate ei;%.er 'Yes' or 'No' as to each of the following: r(/ _ 1 have determined that the system violates one or more of the following failure criteria as defined in 310 CMR t 5.303. The basis (or this detetminalion is idt 6l(ied below. The Board of Health should be contacted to determine what will be necessary to cornea the failure. Yes Now L/ Backup of sewage into facility or system component due to an overloaded or dogged SAS or cessP001. 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 the d sribu}*R box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in feel is less than 6' below invert or available volume I$ less than 1/: day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipets). Number of times pumped _- Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. JAny portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. 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. 11 the well has been analyzed to be acceptable, attach copy of Nycll water analysis (or coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM fA1LS: You must indicate either 'Yes' or 'No' as to each of the following: The following criteria apply to large systems in addition to the criteria above: iYU The system serves a facility with a design flow of 10,000 SO 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 Ng 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 l 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 04/23/17) Y�y• 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST PropenyAddress: 141 Shell Lane Cotuit,Mass. Owner; Patricia Jones Date of Inspection: 1 0/1 9/9 8 Check if the following have been done: You must indicate either 'Yes' or.'No' as to each of the following: Yes N.{.0 / Pumping information was provided by the owner, occupant, or Board of Health. _ Y None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been Introduced into the system recently or / as part of this inspection. Y As built plans have been obtained and examined. Note if they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. _ Z The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout..3ssc_ All system components, luding the Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered, opened;and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions; depth of liquid, depth of sludge, depth of scum. — The size and location of the Soil Absorption System on the site has been determined based on: The facility owner (and,occupants, if cVerent from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. Existing information. Ex. Plan at B.O.H. _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) (15.302(3)(b)) I (r.vl..d 04/3S/77) D.y. 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 141 Shell Lane Cotuit,Mass. Owner: Patricia Jones Date of Inspection: 1 0/1 9/9 8 FLOW CONDITIONS RESIDENTIAL: Design flow: V;D g.p.d./bedroom for S.A.S. Number of bedrooms: 5 1 La+17' Number of current resldents:d Garbage grinder (yes or no): AM Laundry connected to sys em (yes or no): Seasonal use (yes or no): f // Water meter readings, if available (last two (2) year usage (gpd): �� f" �t° Mb 36c'� b Sump Pump (yes or no): .62L Last date of occupancy:J22129— COMMERCIAUINDUSTRIAL: Type of establishment: Alfl Design flow: AJA Rallons/day Grease trap present: (yes or no).,IA Industrial Waste Holding Tank present: (yes or no)—/4 Non-sanitary waste discharged to the Title 5 system: (yes or no)A Water meter readings, if available: 44 AO Last date of occupancy: AA_ OTHER: (Describe) A�l� Last date of occupancy: 4 GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no) If yes, volume pumped: eallons Reason for pumping: fl/b TYPE OFSYSTEM _Septic tank/distribution box/soil absorption system Single cesspool TF Overflow cesspool Al) Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Pfi VA Technology etc. Copy f up to date contract? Other Al� APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes or no) (revised 04/25/97) Pago 5 of 10 O t` ■ �_ 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1 41 Shell Lane Cotuit,Mass. Owner: Patricia Jones Date of Inspection: 1 0/1 9/9 8 BUILDING SEWER: (Locate on site plan) !t Depth below grader Material of construction: _cast iron _L/40 PVC_other (explain) Distance fromu rprivate water supply well or suction line Ib Diameter V Comments: (condition of joints, venting, evidence of leakage, etc.) Joints appear tight. No evidence of leakage. System is venteventedthrough the hottsP vent _ SEPTIC TANK:.( 69AUW (locate on site plan) Depth below grade: Material of construction: concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age AJ4 Is age confirmed by)).�Certificate of Compliance a (Yes/No) Dimensions: 4`�t��Ot�b N�Ir7rrlxdliei Sludge depth Distance from top of sludge to bottom of outlet tee or baffle: Fit Scum thickness: V1 Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How dimensions were determined:AAWIVI, 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.) Pump the tank every 2-3 years;Inlet & outlet tees are in place;Liau d level at the outlet i s f i ft= i nrhag-Tha f-ank i s Strttrtural l y sn"larl and shows Re evidef}ee e€ leakage GREASE TRAP:-&kc (locate-on site plan) Depth below grader Material of construct ion:Al,4 con creteA) metal&�FiberglasvO�f Polyethylene&other(explain) A-4 Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: d _ Distance from bottom of scum to bottom of outlet tee or baffle:'a Date of last pumping: y1 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.) Grease trap is not present. (revised 04/25/97) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 141 Shell Lane Cotuit,Mass. Owner: Patricia Jones Date of Inspection: 1 0/1 9/9 8 TIGHT OR HOLDING TANK: Avg (Tank must be pumped prior to, or at time, of inspection) (locate on site plan) Depth below grade: Vlwl� Material of construction:A concreteA/A metal A/�1 Fiberglass 4IPolyethylene �Jother(explain) NA of Dimensions: #)A Capacity: A14 gallons Design flow: gallons/day Alarm level: (/ Alarm in working order&,4 Yes;/ No Date of previous pumping: uA Comments: (condition of inlet tee, condition of alarm and float switches, etc.) light or o ing an sure no present. DISTRIBUTION BOX:Z (locate on site plan) Depth of liquid level above outlet inven: tb Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) Distribution box has one lateral;No evidence of solids carry over;No evidence of leakage into or out of the box. PUMP CHAMBER: 12 Q� (locate on site plan) Pumps in working order: (Yes or No) 4114 Alarms in working order (Yes or No) W-4 Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) Pump chamber is not present. (reviled 04/25/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 141 Shell Lane Cotuit,Mass. Owner: Patricia Jones Date of Inspection: 1 0/1 9/9 8 SOIL ABSORPTION SYSTEM (SAS):L� �al� (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: t leaching pits, number:_ leaching chambers, number: leaching galleries, number: leaching trenches, number,length: d leaching fields, number, dimensions overflow cesspool, number: b Alternative system: 4);F — Name of Technology: S Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) m Loamy sand to sand;No signs of hydraul i r fa i 1 „re nr pnQr3jn. All yegetatinn is normal. CESSPOOLS: AI&IC (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: 4j Depth of solids layer: 16M Depth of scum layer: kd Dimensions of cesspool: ilGit v Materials of construction: Indication of groundwater: A/W inflow (cesspool must be pumped as pan of inspection) Cesspools are not present Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) Cesspools are not present- P R I VY:%�ze (locate on site plan) Materials of construction: /U/9 Dimensions: Depth of solids: kl/ Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) Privy is not prPRent (revised 04/25/97) Page 8 of 10 n L% SUBSURfACE SE%YACE,OISPOSAI SYSTEM INSPECTION FORM PART C SYSI(M INFORMATION Iconlinutd) P,opcnr Address: 141 Shell Lane Cotuit,Mass. " Patricia Jones 0+11 of inspC0,01%t 1 0/1 9/98 . SKETCH of SEWACE DISPOSAL SYSTEM: inclvdc tics 10 't It'll two Dtrm'ntnl rtferences I'ndmuks or benchmarks 10cpc 'll wells within 100' IlOc'lc wht(c public water supply comes into h0v$t) I aQck of I�ous� o . 1. SUBSURFACE SEWAGE DISPC;r.'l SYSTEM INSPECTION FORM 1':.1:T C SYSTEM INFOR..; .TION (continued) Property Address: 141 Shell Lane Cotuit,Mass. Owner: Patricia Jones Date of Inspection: 1 0/1 9/9 8 Depth to Groundwater � Feet Please indicate all the methods used to determine High Groundwatw Elevation: Obtained from Design Plans on record Observa(ion of Site (Abuning prope bservation hole, basem4rk sump etc.) —ZDetermine it from local conditions Check with local Board of health Check FEMA Maps [-/Check pumping records _zCheck local excavators, installers Use USGS Data Describe in your own words how you established the.High Grounckw,rcrElevation. (Mull be completed) Used water contours map. Gahrety &Miller Model 12/16/94 5 ' (r•vl••d Ot/13/77) 1•y. Ibot 10 �•r•nnr..—n.'A.—•Tr�.nrrw•nen.s-+n+.+.'.r�rarnn-rrwry�nrr�.wm»T1f+ fl�n�1'+n .rn-RT-.gym.—:..t-.r-•., TOWN OF Barnstable (WARD OF HEALTH e-•.�-.•,.,.-T"�- SU[tFACF 9FH�AGF DISPOSAL SYSTEM I NgPRCPION FORM - PART D .- CERTIFICATION I -TYPE OR PRINT CLEARLY- PIIOPERTY INSPECTED STREET ADDRESS 141 Shell Lane Cotuit,Mass. ASSESSORS MAP, BLOCK AND PARCEL # g/Z /9 9 OWNER' s NAME Patricia Jones PART D - CERTIFICATION NAME OF INSPECTOR Joseph P.Macomber Jr. COMPANY NAME J.P.Macomber & Sor�tnc. COMPANY ADDRESS Box 66 Centerville,Mass. 02632 . Street Town or City S t a t I LIP COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX (508 ) 790 -1 578 7R TIFICATION STATEMENT I certify that I have personally inspected the sewage disposaj system nt this nddress and that the information reported is true , accurate , and complete as of the time of -inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check ne., System PASSED , The inspection I+hich I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 16 , 303 , Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . System FAILED* The inspection whic)I I have con ted has found that the system fails to protect the public health and the environment in accordance with Title 6 , 310 CMR 16 . 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . "r , Inspector Signature A A IdDate One copy of this certification must be provided to the OWNER, the BUYER ( where applicable ) and the 130ARD OF )iEAL1111, * If the inspection FAILED, thle owner or'" parator ehall upgrade he ayste within o'ne year of the date of the inspection, unless allowed ortrequiredm otherwise as provided in 3,10 CMR 16 . 306 . partd .doc C•/ * - C- W S. 7 � THE COMMONWEALTH Off'- MA.SSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION BE IT KNOWN THAT Joseph P. Macomber, Jr. Has satisfied the Department's qualifications as required and is hereby authorized to use the title CERTIFIED TITLE S SYSTEM INSPECTOR as provided in 310 CMR 15 .340 and Section 13 of Chapter 21A of the General Laws. Issued by The Department of Environmental Protection. hmc Acuity, Dircctur Of 01c l) i lull ul Watcr Pollution Control A 1 V Fs .-f 2::..L.i.C.1. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH .3 _ .�/� OF................qr'..3...*----------•---•-. e. ApplirFation for Uhipaii al orko C�omi rurtiun Prrutit Application is hereby made for a Permit to Construct (a ) or Repair ( ) an Individual Sewage Disposal System at: ' Y-e-k .... _-- ........... • -- •---•---•._...-•................•----- •-•--...._......_------=-•�•----..... -•--•--------------------•---•----------- Loc • _Address or Lot No. L c f. G Jll4 N.:........................:-34 {.�C �....... .......... ......_... ... Owner Aes c... -t '® wa h1./Y.....--------- Installer Address Q ype of Building Size Lot._ZO,___/f—O------Sq. feet V Dwelling—No. of Bedrooms______________________________ _ _Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons____________________________ Showers — Cafeteria W Other fixtures -------------------------------- -- - W Design Flow............................S.3_'-----gallons per person per day. Total daily flow..__.__..___._3_3__0___._._______.___gallons. WSeptic Tank—Liquid capacity/uoa._gallons Length_ '._G"_. Width_y�� Diameter................ Depths'_7 x Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No----------/_........ Diameter_/e__'_o_"__ Depth below Total leaching area...zG__7....sq. ft. Z Other Distribution box ( OK) Dosing tank ( ) Or Jr '-' Percolation Test Results Performed by:____ _r_ -._:s"' �,Y! __. - Date__ Kcr_._/ _19.1 Test Pit No. 1.....Z_-------minutes per inch Depth of Test Pit... Depth to ground (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ o_3---------------7� f/••-•-•--. O Description of Soil...........'3 d .�-/�v`! ...............i` ``r -Sq K -----•-----------•----•----------------•---•------------•-.._..-•---------• x V ._..-•.................•-----•--------------•----------------._._...------/--------..__...-•-•--•--•--------•--•-•----------------------•----••------•-•---------•-----•--------•--••---....._..--••---- UNature 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 TITL% 5 of the State Sanitary Code—The undersigned further rees no to place the system in operation until a Certificate of Compliance has been iss d by the boar I Xt Signed___.._._.. w"7_'.....__�_. �e� Date Application Approved BY ��.o^'' =� ' ._.._..--- Date Application Disapproved for the following reasons---------------------------------•-•---------------------------------------------•------------•••------------•... ....................••---------------•--......----••--------•---•-----------------------•--•-•-----•-••-•-------•••--•-•-••----....---•------•---•----•-•----------•-•-•----••---•---------•••......--- Date PermitNo....... .:-... d ----••-•-•------•--• Issued....................................................... Date THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) mA- F t L DATA No..Q .......................... _ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............ OF ` - d �p Appliration for Disposal darks Tonutrur#iurt jinmit Application is hereby made for a Permit to Construct (y ) or Repair ( ) an Individual Sewage Disposal System at: ......................................................•........................................... ................_..................................__............................................. /1/,' V Lo tion-AddresV or Lot No. 11 ,.................................................................................................. .................................................................................................. �Ouwnerr Address :.. ,t a r r. �� r/ Q fv+(NAddr ss'� ype of uilding 9 Size Lot.-"11,-- ems-......_..Sq. feet Dwelling—No. of Bedrooms......................;...................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers — Cafeteria QI Other fixtures ------------------------------------•------------------•--------------------------------------------...----- , d ..... .................................. _ W Design Flow........................................_._-gallons per person per day. Total daily flow.............................................gallons. WSeptic Tank—Liquid capacity`'``...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...2,1.7._..sq. ft. Z Other Distribution box Dosing tank Percolation Test Results Performed by............................................................�r ''�` ''`'.. �";.% fDate Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water_......................... (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.................... _ Descriptionof Soil....................................................................................................................................................................... V / W �u.._.'. -=-I'G✓,r/w r mac. ore e Lti`q r -•----•--•----------•................ .. . . ---._...----••-•--•-......................... •-------••--•---•--•--•-•-•------..........................---•------- UNature of Repairs or Alterations—Answer when applicable............................................................................................... --------•-------------------•--------------•--•---------•--•-------------------------•----••------------•---•------------------------------------------•---------....--=---•---•--•-...........•------•- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed f✓� �� e` � V ate Application Approved BY ... --------.r•..,.... Date Application Disapproved for the following reasons:-----....-•-----------------------------•--------------•---•-------------------------------............-•--•---- ........................................... .... ..... ..................... Date PermitNo..................................................... Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS = BOARD OF HEALTH a-lam ...............................OF......_, G. .F�i......... ! ...................... ................... Tatifiratr of Tuutpliatta T IS TO CERTIFY, That the Individual Sewage Disposal System constructed (,bG) or Repaired ( ) at---...��-�---�f/�•. -. __->_7`_. ._ L ---------•---••-•-•----•---------------•----•-----...---------------- has been installed in accordance with the provisions of TIT _5,orf State Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM;ILL R NCTION SAT SFACTORY. DATE !!;L Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD O HEALT -•� f7-ygj .................OF.......... .. No......................... FEE........................ Disposal Works Tunutrurtian Uprrutit Permission is hereby granted... % � I to Construct ( ) or Repair ( ) an Indi IduaI Sewage Disposal Sy�t- atNo...------ l -•... A... ' ........ .............................................. Street as shown on the application for Disposal Works Construction Permit No..................... Dated....... �--a~ i zr/yeF7 o rd of ....................------- DATE.-- --- � Health FORM 5 � S & WARREN. INC.. PUBLISHERS nigh f S YS TEM PROFILE NOT TO SCALE TOP FON. FINISH GRADE y2'• FINISH GRADE OVER EL . ^. • ;a::.a,:,_ FINISH GRADE OVER DIST. BOXY FINISH GRADE AVER °"• '' SEPTIC TANK . LEACHING PIT *x. e� VARIES / • �.•Q:0' :0••p •.o{a. •'q,o•�•. ••o':••o:'.i'•o::.o•;••e.'•a:�,,:!.o';:;'. •d.' "e••r, •.'6• �. .• o:.b ;.:.a p :.e:..:e:: . .. .o. :; . ..:. .:a•'o.e:a •o. PRECAST CONC. OR °"`• ASHE PEA STONE •,- .:...o:• O; 3„ e: 1 OUTLET PIPE LEVEL BRICK 6' MORTAR TO 12" BELOW GRADE FOR 2 FT. MIN. a,...:e::e le:• o: :a: o o.• . e o • Fe. 7,a C. I. OR PVC TEES C. •p ?: o.o•. ®. o.o. BSMT. FLR. oo'oo ;, �. '-:' " ;' GALLON o. o': rio OISTRIBUTION BOX EL o ° PRECAST CONCRETE INSTALL ON LEVEL BASE 3/4" TO 1-1/2" a 6 A PRECAST :a: '°'.•;.•D. °:;: e ' WASHED I H— 0 REINFORCED I °• •q CRUSHED CONCRETE 't b,°;o:•o°o o�o�c':oA'o,p`o:Do�itoQo'°o aQo:o o�:•°a:esso.000000. STONE •y H— /0 REINF. SEPTIC TANK INSTALL ON LEVEL BASE ° ° ' 4. °•'o.o.°.;o..� NOTE.' EXCAVATE TO ELEV. OR . a.,. .:a''-�a: ; � .Q:p•' A' ° D• , , L OWER TO REMOVE AL L IMPERVIOUS CIA TERIAL BENEA TH THE LEACHING AREA REPLACE EXCA VA TED MA TERIAL WI TH CL EAN. CL A Y FREE SAND rp v EFFECTIVE IAMETER � I 4 GENEriAL NOTES LEACHING PIT INSTALL ON LEVEL BASE X' ;,�- ' �o f ��. 1. ALL EL EVA TIO1IS SHOWN ARE BASED ON 4 53 Y/' J 1 i 2. ALL PIPES IN THE SYSTEM MUST BE CAST IRON OR sCHFDU1.F 44 PVC. OBSER VA TION PI T �2. 3. THE BOARD Of" HEAL TH MUST BE NOTIFIED 0 WHEN CONS TRUE"TION IS COMPLETE PRIOR TO BACKFILL IPG PERCOLA TION RATE: 4. ANY CHANGES .IN THIS PLAN MUST BE APPROVED Z, MIN./IN. 9` -'a. Z o" WI TNESSED B Y.• -___._. ____ ___ _ Q_ / ., _ ? BY THE BOARD OF HEALTH AND CAPE 6 ISLANDS 4.1 'IleSURVEYING CO,, INC. '�' _ , 9 s 3't 'CAST COIVCqeTE ` 5. MA TERIALS ANC INS TALLA TION SHALL BE IN �_. �' _ cEACHrntG P�r COMPLIANCE WI TH THE S TA TE SA NI TARP BRO. OF HEALTH DESIGN DA TA H e lee rTE: .` CODE — TITLE V — AND LOCAL APPLICABLE DA T RULES AND REGUL A TIONSRf .o 1000 SALLOW �' H, / 6. NORTH ARROW .,T c FR!)A1 RECORD PLANS AND �i i NUMBER OF BEDROOMS PRECAST COWCRET�., . /0 t i.a t T o pS c , SEPTIC TANK L raI IS NOT TO BE USED FOR SOLAR PURPOSES GARBAGE DISPOSAL 'G yZ " _} 7. FLOOD HAZARD ZONE S v b �� DAILY FLOW GAL . 8. WA TER SUPPL Y ____ r�,�, GA L ' '�' ' `� " SEP TIC TANK RE•O D. ' N . .3 B'.- m.s `p SEPTIC TANK PROVIDED GAL . �o L EA CHING REOUIRED c GPQ. 19 4 i f el C ct r v..a SIDEWALL AREA 1e8 S. F. S.F.X 2,-$" G/S.F. _ �?/ GPD N 4,9• 30• z�� r,,�,,,p BOTTOM AREA S.F. / LEGEND i ly S.F.X F. _ GPD IZ { 'w L EA CHING PRO VIDED GPD N. W.4-11 PROPOSED EL EVA TION iyv V�" .__...__. — --___ . �.—.__._........__.._.._._..._._�..�..._.__._�.w. •..._._...��._. .___._ ...._,_.__. ..,..,__..-, ——v-t — EXISTING CONTOUR — OBSERVA TION PIT SINGLE FAMILY RESIDENCE G ❑ DISTRIBUTION BOX PROPOSED SEWAGE DISPOSAL S YS TEM 0 Li ti CHING PIT `3 PREPARED FOR V D D SEPTIC TANK �� :� � MCSHANE CONSTRUCTION ARP 1 RESERVE ` L O T 19 OAKWOOD S TREE CO TUI T — BARNS TABL E — MASS. PIPE INVERT ELEVATION DA TE.' Ile - PLOT PLAN CAPE 6 ISLANDS SURVEYING, INC. A NO SCALE S T SCALE.• 1 "_ ��� � f��,2 ��,� P. O. BOX 334 TEA TICKET, MASS. M4 f SEC PCL LOT HSE `' .� •. '` ' FPL NO. - 'r51 "