HomeMy WebLinkAbout0012 TRACEY ROAD - Health 12 Tracey .oad
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THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Ye�,�/
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
01pprfcation for Migpool bpotem Construction Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 12 ' Owner's Name,Address and Tel.No.
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Assessor's Map/Parcelc o—t-0;r �r�/z'�n/"rX t ce
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
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Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building gel! No.of Persons Showers( ) Cafeteria_( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) jue_.) joa;z: &O X 3
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 Board f Healt .
Signed Date 7—Jr-•-0 2
Application Approved byt2movDate
Application Disapproved or the following reasoe_t!��,--�
Permit No. Date Issued
y�ry
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Fee Sin. 0
i ' R THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
w = PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS es
0[pprication for �Bigogal 6pgtem Congtruction Permit
Application for a Permit to Construct.( )Repair( )Upgrade( )Abandon( ) El Complete System ❑Individual Components
Location Address or Lot No. /;?„ 774 C* /Q Owner's Namee,Address and Tel.No.
Assessor's Map/Parcel - ! �C 0��� �� � ��,.v
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Installer's Name,Address,and Tel.No. 7� yy Designer's Name,Address and Tel.No.
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Type of Building:
i
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building Poq. No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons. r
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank ,t;r7,sZg:ig /Cns,irk2- Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) own , .�
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 Board f HealtV445Z.Icr
SigneAthe
C. J.aDate
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Application Approved byr U Date
ir
Application Disapprovedwing reaso
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Permit No. A " Date Issued
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THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired(X)Upgraded( )
Abandoned( )by
at tp_ nx4oca_ �/ w a U has been,constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No idated
li Installer &r, jj� Designer
The issuance of this perjnit shall not be construed as a guarantee that the system will unction as de 'gned.
Date 7 11 -7 / V a- Inspector 4N
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No.
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THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
XigPo!gal *pgtem Conotruction Permit
Permission is hereby granted to Construct( )Repair Upgrade( )Abandon( )
System located at
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:Construc i r n mu t degc�oT leted within three years of the date of s pe .�.
Date: (/ Approved by
a
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TITLE 5
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEIVED
PART A
CERTIFICATION
� JUL 2 5 2002
Property Address: 12 Tracy Road TOWN OF BARNSTABLE
COtuit,MA 02635 HEALTH DEPT.
Owner's Name:John Fitzpatrick
Owner's Address:Same <:;4 X (3 '
Date of Inspection: 7/11/02 i
Name of Inspector:(please print)Janet E.DuPont PARCM ._ 1r3(p 5
Company Name:Wind River Environmental LOT
Mailing Address: 120 Great Western Road
South Dennis,MA 02660
Telephone Number: 508-760-4827
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:
X Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: -��--= =Y.2,
The system inspector shall s?mitcopy 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 Observation of the site and measurements of the inlet and outlet ends indicates that
the tank is slightly off level which explains why water levels in the tank are slightly over inlet invert level
and at outlet invert level. There are no indications of backup however and tank appears to be functioning
as designed.
""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.
r
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 12 Tracy Road
Owner:John Fitzpatrick
Date of Inspection: 7/11/02
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
_X_ I have not found any information which indicates that any of the failure criteria described in 310
Cl R 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced
or repaired.The system,upon completion of the replacement or repair,as approved by the Board of
Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements.If`not determined"
please explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is
structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board
of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to
broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System 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:
f
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 12 Tracy Road
Owner:John Fitzpatrick
Date of Inspection: 7/11/02_
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
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 salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines
that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the 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 welly*.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 facilityand the presence of ammonia nit
rogen itro en and nitrate '
p g t 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:
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OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 12 Tracy Road
Owner:John Fitzpatrick
Date of Inspection: 7/11/02
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
T _X_ Backup of sewage into facility or system component due to 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 SAS or cesspool
_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 %day
flow
T _X_ Required pumping more than 4 times in the last year N_QLdue to clogged or obstructed
pipe(s).Number of times pumped
X_ Any portion of the SAS,cesspool or privy is below high ground water elevation.
_X_ Any portion of 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 I 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. [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.]
_No (Ye&No)The system fails.I have determined that one or more of the above failure criteria
exist as described in 310 CMR 15.303,therefore the system fails.The system owner should
contact the Board of Health to determine what will be necessary to correct the 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-IWPA)or
a mapped Zone 11 of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or
answered"yes"in Section D above the large system has failed.The owner or operator of any large system
considered a significant threat under Section E or failed under Section D shall upgrade the system in
accordance with 310 CMR 15,304.The system owner should contact the appropriate regional office of the
Department.
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address, 12 Tracy Road
Owner:John Fitzpatrick
Date of Inspection: 7/11/02
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
_X_ — Pumping information was provided by the owner,occupant,or Board of Health
_ _X_ Were any of the system components pumped out in the previous two weeks?
_X_ _ Has the system received normal flows in the previous two week period?
— _X_ Has large volume of water been introduced to the system recently or as part of this inspection ?
_X_ — Were as built plans of the system obtained and examined?(If not available note as N/A)
_X_ _ Was the facility or dwelling inspected for signs of sewage back up?
X_ T Was the site inspected for signs of break out?
_X_ ____ Were all system components,excluding the SAS,located on site?
_X_ _ 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 ?
_X_ _ 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
_X_ — Existing information.For example,a plan at the Board of Health.
_X 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)]
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 12 Tracy Road
Owner:John Fitzpatrick
Date of Inspection: 7/11/02
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):_3_ Number of bedrooms(actual):_3_
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):_330
Number of current residents:_2
Does residence have a garbage grinder(yes or no):No
Is laundry on a separate sewage system(yes or no):No [if yes separate inspection required]
Laundry system inspected(yes or no): _
Seasonal use:(yes or no): No
Water meter readings,if available(last 2 years usage(gpd)):2000—97,000 gallons 2001 - 113,000
gallons
Sump pump(yes or no):No
Last date of occupancy:_Current
COMMERCIALANDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15:203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):_
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:_Pumped post inspection 7/11/02 Wind River Environmental
Was system pumped as part of the inspection(yes or no):Yes
If yes,volume pumped: 1000 gallons--How was quantity pumped determined?Site Glass
Reason for pumping:—Maintenance
TYPE OF SYSTEM
—X_Septic tank,distribution box, soil absorption system
_Single cesspool
Overflow cesspool
_T 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 all components,date installed(if known)and source of information:
_17 Years old according to sewage permit 84-794
Were sewage odors detected when arriving at the site(yes or no):No
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 12 Tracy Road
Owner:John Fitzpatrick
Date of Inspection: 7/11/02
I
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction:`cast iron _X_40 PVC_other(explain):
Distance from private water supply well or suction line:_20+'_
Comments(on condition of joints,venting,evidence of leakage,etc.):
_Normal
SEPTIC TANK:_(locate on site plan)
Depth below grade: 16"
Material of construction:_X_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: 1000 gallons
Sludge depth:_6"
Distance from top of sludge to bottom of outlet tee or baffle: .
Scum thickness:3"at inlet end
Distance from top of scum to top of outlet tee or baffle, 10"
Distance from bottom of scum to bottom of outlet tee or baffle:
How were dimensions determined:_Probe
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,
liquid levels as related to outlet invert,evidence of leakage,etc.):Tanks does appear to be slightly off level
due to levels at invert of outlet and inlet.,baffles are in place and tank shows no signs of leaking. Inlet
pipe has slight;downward pitch into tank. Pumping was done at request of owner for maintenance.
GREASE TRAP:_,,,_(locate on site plan)
Depth below grade:
Material of construction:,concrete____metal—fiberglass_polyethylene other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,
liquid levels as related to outlet invert,evidence of leakage,etc.):
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 12 Tracy Road
Owner:John Fitzpatrick
Date of Inspection: 7/11/02
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass_polyethylene other(explain):
Dimensions:
Capacity: 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: X—(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:Liquid at invert of outlet
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.):D-box was replaced.Certificate of Compliance on file
Barnstable Health Department.
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.):
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 12 Tracy Road
Owner:John Fitzpatrick
Date of Inspection: 7/11/02
SOIL ABSORPTION SYSTEM(SAS):_X_(locate on site plan,excavation not required)
If SAS not located explain why:
Type
X leaching pits,number: 6Ft
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,etc.):
Pit appeared to be normal. Contained 2 Ft.of standing water with some sludge type material at bottom,
no signs of ponding or breakout,normal vegetation.
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum Payer:_
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.):
. . ....... _... ..: .. ... .
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 12 Tracy Road
Owner:John Fitzpatrick
Date of Inspection: 7/I1/02
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.
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OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 12 Tracy Road
Owner:John Fitzpatrick
Date of Inspection: 7/11/02
SITE EXAM
Slope Level lot
Surface water None
Check cellar Normal
Shallow wells
Estimated depth to ground water 17.8 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)
_X_Checked with local Board of Health-explain: Accessed water table records and adjustment figures
on file Barnstable Board Of Health dated June 1992,also accessed site elevations on file
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
SAS site is at elevation 33.6' A.S.L.per maps on file Barnstable BOH
Groundwater elevation is less than 5'A.S.L.per map on file Barnstable BOH dated June 1992
Site is monitored by well M1W 29 Zone A. Adjustment for Maximum Potential Rise June 1992 is 1.8'
Bottom of SAS is 9'below grade
33.6—(9+ 1.9 =22.8 22.8(bottom of SAS adjusted for MPR}—5.0(water level)= 17.8
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/v .............OF......... �YJ �'� -+1 ..........................................
ApplirFa#inn for Bwvoiial Works Tnnitrurtinn Prrutit
Application is hereby made for a Permit to Construct O or Repair ( ) an Individual,'Sewage Disposal
System at: Q
1`.Y .': io..................................... ------------- C.T ................... .....---• ------------.........-----
.... .... -• --
ocation-Address t or I0C
.. +.� .. :.----•-q.U.V,,.8 �� .......•.... .......Y�1 �. --- .--N y eA�--•...................
W `y Owner Address
................................. ......•........................... ..........
Installer Address '
U Type of Building Size L t�._0�_Y?..........
�
U Dwelling—No. of Bedrooms........... ________________•_-----------Expansion Attic ( ) ��[ Garbage Grinder_ ( )
'4 Other—Type of Building No. of persons__-•________________________ Showers — Cafeteria
cw Other fixtu es ----------_------------ ---- -
Design Flow......................5................gallons per person ,per day. Total daily flow.._....*_9.0...__._.._.__....•.•..._gallons.
WSeptic Tank—Liquid capacity>l __gallons Length___ _--___.... Width_Y4___- Diameter________________ Depth_V=-Q.__.
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 ( ) Dosingrtank I ( `_ t
'-' Percolation Test Results Performed by._-VCR trVI. ..- rll� ._.. ....... Date....
Test Pit No. 1 --minutes per inch Depth of Test Pit------` ......... Depth to ground water------J/P -----
(i, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to groun ...
a --- --.-----------------------•------- --------------•----------------------------------- ---------
1
O Description of Soil-•-----h'1------.wkn 5 ------•--•--•--------------------------------------------
N
W . .. H
Nature of Repairs or Alterations------------------------------------------------------------------------------------ ----- - --- ---- -- -----
U p i--ns—Answer when applicable--------------------------------------- �- ----••-
'o ani �►
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in-accordance with
the provisions of iITL is 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bten issued by the board of health.
Lb ..................................................... . ............----
ApplicationAPPr --•-- ---- --- ----•-------•-•--------....-•---............._..........................•..... ........ •---
Date
Application Disapproved for e f olio ing reasons----------------------------------------------------------------------------•--•------------------------•••-•---
•--•-•---------------•---------•-----•--•• . .. ••.... ----•--------•...-•---------•-----•--••••••--
Date
Permit N-g-f---------- ••---- . ................... Issued....•...... v! - '..................
t
FE$..........:..................
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OE HEALTH
...:_f'.C..«d.................OF.......... ... l_O_Acll. Ic..........................................
Appliratiun for Disposal Works (9mm rndinn runfit
Application is hereby made for a Permit to Construct Lk/) or Repair ( ) an Individual Sewage Disposal
System at:
.... -•--
&^Location Addressc^ or Lot
t
. .... rr�r 6 __.i t L LII.Tf f, � 1•E_ly¢ e— y 5. 4_lei.... 1 f.. 1� t dL:�1};d.........................-
Owner I Address
W
� Installer Address ,_ �.
d Type of Building ,- Size Lot._O.=i11:'2..........sq. gat
aDwelling—No. of Bedrooms_..............................._...........Expansion Attic ( ) Garbage Grinder ( )
pa Other—Type of Building ____________________________ No. of persons............................. Showers ( ) — Cafeteria ( )
Otherfixttpres .----•--•-----•-•••-----•---•---•-•••--•----•••--•-•---•-•••------ -- r
W Design Flow......................_: _______.._..._____gallons per person per day. Total daily flow--------:�.2 0__.______.____._.`..____gallons.
R: Septic Tank—Liquid capacit)------------gallons Length__-.. .__. Width.`-(..... Diameter________________ Depth_`;<_`_o.._..
Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No________ ___________ Diameter___ . Depth below inlet...... ,t_________ Total leaching area _ :______sq. ft.
Z Other Distribution box ( ) Dosin tankj( ) ,
`" Percolation Test Results Performed b . fi t_.° € _! +�' l E�___._,r°; Date___ ._+�' o
,.4 Test Pit No. 1_.;KI?':___minutes per inch Depth of Test Pit---/!Z........... Depth to ground water......hCJhe.......
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to grou _ ._________-_.
w
O Description of Soil....... ---`.C'-!0------•----•-•-•--•---•---•--••------------------------
x
(� ...LEE-------- Vi
HAS N
W •-
U Nature of Repairs or Alterations—Answer when applicable-------_------------------- �'A�
--=
......................... C .,��S. .
Agreement:
dMA ��
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITIZ 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has en issued by the board of health.
�gne!d............. ........................................... .......Z/....
ApplicationAPpKeySd BY ---------•-----------------------------------------•-•-.._._..__.--- ...�•---•5 ---�a --•---.
-- Date
Application DisapprovVforeing reasons------------------•------------------------------------=---=------------------------------------------...._-•----
Date
Permit No. - Issued ---f•�----.....•-.tj---1...----•---•---
Date
THE COMMONWEALTH OF MASSACHUSETTS
}
BOARD OF HEALTH
...........................................OF......._.%'........:.._:.":Gs. ..............................................
�rrtifiratr of fuutplinnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
(G r-€ --•---•---•-----�---•------------------•---•-------------•---------------------------------------:------•---•-•-•------•------------
y.......................--•-• ------------- r , /} Installer
rt.
has been installed in accordance with t4 provisions of T "�Lv, rPf e State Sanitary Code as described in the
application for Disposal Works Construction Permit No-------------------
dated-...............................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CO STRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE..............�...... ......... Inspector_..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�� rt, OF.. .c �x>; .. ........................................ �?
No ..................:.... FEE... ...............
�iu�uu�l urk� �un,��riun• rrnti#
Permissionis hereby granted..............................................................................................................................................
to Construct (b<) or_Repair ( ) an Individual Sewage Disposal System
r � ..
l Street
as shown on the application for Disposal Works Construction Permit f'_-.-................... Dated..........................................
...--------•--••-------•----- ............................................................
/ Board of Health
DATE •----------------------------•• //
FORM 1255 HOBS & WARREN, INC., PUBLISHERS
fz- Sewage Permit No.
Location: 6-T- Li C Ox
Village: FE
Installer's Dame & Address: +W C.oh-(LU3\,ayS nc_
i
Builder's Name & Address:
Date Permit Issued
Date (compliance Issued
� a
' Cr�l
� tiw
r
I c o
e,. ..
. ; l
r
PRECAST LEACHING P/T L -t
i M.H. CQver„to wilhrn PRECAST SEPTIC WANK (NOT TO SCALE)
/2"of AWM Grode'-�
3 `9 SO FT. P/r .
• / •••• •p 3 it l /N /V of '
r �1N lIl O O O 0 ❑ a
Z20 WASHED
i . t 2"WA SHED0 0 0 o t� 0 0 0
OU STOAI£:% TO ih" 0 0 0 o�p o 0 0 o STONE: �e"TD%t�
., I = nt
o 0 o p r o 0 0
�P� tiw�c� +•� //I/ WASHED a a o CO 0 o a WASHED
B=0,0 uL STONE:��TO/ ' j' STONE:W ro I f ul
f o 0 0 0 0 0 o a
E X�anS t a n ';•
IF
Aiea
••. 3 _Op Ile
6 _0
p
►° NOTE= IF THE L/OU/D DEPTH OF THE SEPTIC TANK /S
31FEET, THE OUTLET TEE SHALL EXTEND /9 p SOIL LOGS
is
B EL Ow THE FLOW L/NE.
T. P. / T. P. 2 T.P. 3 T. P. 4
r
O vpo47
S
10p0za 16,1 G. liar►3, cc betv3g �t /e� +0
nK
_ 1i�w +fie tru£�� {U be evl�hty) }
l4 2/ O'4 fUtJO$ Qt �GC�►VIG� �1t .
/ Ilk
/� �UjX1SQQ -
Live
s - ___♦\7h// o �r S �. I PERCOLAT/ON RATE OF M/NU ES / INCH.
99x, - , TrX? PRESENT DURING TESTS l
� ., /_ . � - ' AGENT = ` •, ``.
r
N
SEC TION THRU S YS TEAS/
tI (NO T rQ SCAB.E)
Ac,& E _ �- M H Cover to within /2 of Finish Grode
OIL,
SCA 40
t 4 f/0.1 or PVc.. 7
i�{� v Soli PYC.
SEPTIC TANK
LEACH/No P/T
mc
/0'
(MIN)
20 '
PROPOSED FLOW LIAV GRADES BENCH MARK —DESIGN CRITERIA
INK Ar AOMDAT/ON f �_ �'7u cad G r � � DWELLING , '��.. ' �_` �C 3 BEORaoM A r PROPOSED SANITARY S Y TEM
//0 G.P.6tD. 3_ 6. P. D. ��� y' -r�'GCeq 1KW,
/NV INTO SEPTIC T+ANK� �Pf�. - t` .,.�b fr� �� �
/N K OUT OF SEPTIC,rmw l G �x !2=r,' e,a��I`y �%� - � DRAWN FOR :
/M/ INTO D/ST. B4X S►�ew f 2 �" ,� .. (l '
Rum
1/YV• QtlT OF OIST. :i�DX •fr r» �Fo, - " l a ,�
/� x /� p �� 3 g4;ia►- , VAUTR/NOT S WEBBY CO. COUNTY RD. PLYMPrON, MASS.
u � .,n ��-� SHEET PL AN NO.
INK, INTO L EACJ'M6 PIT /c, '� o c 6 7� 9 a l/a,�,; '��`� ARAN0N BY: �J, E: v)
�,-ram,t ,, r3 39 „f' -�.:
BATTOA/ OF L EACH/Mfg P/T CHECKED BY'
Wi f ER MOLE
APPROVED BY
k
PLAN DATE: YYi* r b 12 SCALE
e ur,4 :