HomeMy WebLinkAbout0213 HICKORY HILL CIRCLE - Health 21.3 Hickory Mill Circle
Y Osterville
A= 121 031
COMMONWEALTH OF MASSACHUSETTS
` EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 213 Hickory Hill Circle
Osterville. MA 02655
Owner's Name: Pat.&John Sheehy
Owner's Address: O`
Date of Inspection: September 8. 2006
Name of Inspector: (Please Print) James M.Ford
Company Name: James M. Ford
Mailing Address: P.O.Box 49
Osterville,MA 02655-0049
Telephone Number: (508) 862-9400
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 o iy a
c
training and experience in the proper function and maintenance of on site sewage disposal'systems.1.1 am a BtP ,.
approved system inspector pursuant to Section 15.340 of Title 5 310 CMR 15.000 . The s ste
PP Y. P P ( ) Y
✓ Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving AUM
rity
Fails
Cn
Inspector's Signature: Date: Se tember 12 006 cn rn
The system inspector shall.subm t a copy of this,inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is'a shared system or has a design flow of 1.0,000
gpd or greater,the inspector and the system,owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use. .
Title 5 Inspection Form 6/15/2000 page 1 '
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 213 Hickory Hill Circle
Osterville, MA
Owner: Pat&John Sheehy
Date of Inspection: September 8, 2066
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments: .
B. System Conditionally Passes:
I
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 broke_n or.
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health):
broken pipe(s)are replaced..
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 213 Hickory Hill Circle
Osterville, MA
Owner: Pat&John Sheehy
Date of Inspection: September 8. 2006
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
I
2. System will fail unless
y u ess the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well**. Method used to determine distance
**This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other: d -
3
Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 213 Hickory Hill Circle
Osterville, MA
Owner: Pat&John Sheehy
Date of Inspection: September 8, 2006
D. System Failure Criteria applicable to all systems:
You must indicate either"yes"or"no"to each of the following for all inspections:
Yes No
✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than''/z day flow
✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped—
✓ Any portion of the SAS,cesspool or privy is below high ground water elevation.
✓ Any portion of 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. [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 (Yes/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 System:
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 II of a P ublic PPY water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered'
"yes"in Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
4
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 213 Hickory Hill Circle
Osterville, MA
Owner: Pat&John Sheehy
Date of Inspection: September 8, 2006
Check if the following have been done: You must indicate"yes"or"no"as to each of the following:
Yes No.
✓ _ Pumping information was provided by the owner,occupant,or Board of Health
✓ Were any of the system components pumped out in the previous two weeks?
✓ _ Has the system received normal flows in the previous two week period?
i
_ ✓ Have large volumes of water been introduced to the system recently or as part of this inspection?
✓ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
✓ Was the facility or dwelling inspected for signs of sewage back up?
✓ _ Was the site inspected for signs of break out?_
✓ Were all system components,.exclu ding.the SAS,located on site
✓ _ Were the septic tank manholes''uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
✓ _ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
,
The size and location of the Soil Absorption System (SAS)on the site has been determined based on:
Yes No
✓ _ Existing information. For example,a plan at the Board'of Health.
✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [310 CMR 15.302(3)(b)].
5
Page 6 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 213 Hickory Hill Circle
Osterville, MA
Owner: Pat&John Sheehy
Date of Inspection: September 8: 2006
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)`. n/a [if yes separate inspection required]
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings, if available(last 2 years usage(gpd)): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: Currently occupied
COMMERCIAL/INDUSTRIAL
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 1 year ago for maintenance,
Was system pumped as part of the inspection(yes or no): No
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
✓ Septic tank,distribution box,soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) (if yes,attach previous inspection records, if any)
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:
Installed on 10125194-per as built
Were sewage odors detected when arriving at the site(yes or no): No
6
Page 7 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 213 Hickory Hill Circle
Osterville, MA
Owner: Pat&John Sheehy
Date of Inspection: September 8. 2006
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: _cast iron _40 PVC other(explain):
Distance from private water supply well or suction line: .
Connnents(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: 24"
Material of construction: ✓ concrete _metal _fiberglass _polyethylene
_other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or,no): (attach a copy of
certificate)
Dimensions: 1000 ag l
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 30"
Scum thickness: 3"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: 10"
How were dimensions determined: Measuring stick
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.).
_Tees were present. The liquid level was even with the outlet invert There did not appear to be any signs of leakage The inlet
cover was 11"below grade.
GREASE TRAP: None (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 baffler
Date of last pumping:
Conunents(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels'
as related to outlet invert,evidence of leakage,etc.):
7
Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 213 Hickory Hill Circle
Osterville, MA
Owner: Pat&John Sheehy
Date of Inspection: Sentember.8, 2006
TIGHT or HOLDING TANK: None (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: ✓ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: Even
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.):
The D-box was level. No solids were present.
PUMP CHAMBER: None (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no)
Comments(note condition of pump chamber,condition of pumps and appurtenances;etc.):
8
Page 9 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL•SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 213 Hickory Hill Circle
Osterville, MA
Owner: Pat&John Sheehy
Date of Inspection: September 8, 2006 E
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) '
t
If SAS not located explain.why:
Type , F
✓ leaching pits,number: I-4'x S'(600 aQ 1.)
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.):
The leach pit had P ofliguid on the bottom. The scum line was at the same level There did not appear to be anv signs of failure The cover
was 28"below grade
CESSPOOLS: None (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: s
Depth of scum layer:
Dimensions of cesspool:
Materials of construction: a
Indication of groundwater inflow(yes.or no):
Comments (note condition of soil,signs of hydraulic failure,level of ponding;condition of vegetation;etc.):
PRIVY: None (locate on sitenplan) s
Materials of construction:
Dimensions.-
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level'of ponding,condition of vegetation,etc.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 213 Hickory Hill Circle
Osterville. MA
Owner: Pat&John Sheehy
Date of Inspection: September 8, 2006
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.
A
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.+ Page 11 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 213 Hickory Hill Circle
Osterville, MA
Owner: Pat&John Sheehy
Date of Inspection: September 8, 2006
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 25 +/- feet
J
Please indicate(check)all methods used to-determine the high ground water elevation:
Obtained from system design plans on record-If checked;date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
✓ Checked with local Board of Health-explain: Topographic and water contours maps
Checked with local excavators,installers-(attach documentation) _
Accessed USGS database-explain-
You must describe how you established the high ground water elevation:
Using Barnstable topographic and water contours maps the mans were showing gpproximately 25'+/ to groundwater at this
site.
21
This report,has been prepared only for the septic system and components described herein. This septic system has been
inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will
function properly in the future. There have been no warranties or guarantees, either expressed, written or implied,
relating to the septic system, the inspection, this report and/or any components of the septic system which have not
been located and inspected.
11
TOWN OF BARNSTABLE
LOCATION a13 14,0 0)(C . SEWAGE# yJ('-
VILLAGE STfv ASSESSOR'S MAP&PARCEL /cP— 03/
INSTALLERS NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) yaCG (�.?' (size)
NO. OF BEDROOMS .3
OWNER S GG�y
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Botween the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) . Feet
FURNISHED BY -v1 For C,
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A (3
3
J �AOy/T6WN OF BAR 6S 1—E
LOCATION LUT - I+-,JLoP-i Wtk Cif- SEWAGE #
VILLAGE 2yollt ASSESSOR'S MAP & LOTIVI--' 15
INSTALLER'S NAME & PHONE NO. [� , J . ���� Lc<g vA euA S .
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SEPTIC TANK CAPACITY
LEACHING FACILITYAtype) (size) 1900 11�-
NO. OF BEDROOMS -3 PRIVATE WELL OR PUBLIC WATER PJb1<<
BUILDER OR OWNER M A--C1Lwoo Q C R +Q,
DATE PERMIT ISSUED: 7- k
DATE COMPLIANCE ISSUED: 'I
VARIANCE GRANTED: Yes No
it r
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�r�kvR l- ,- ( C 2c,C
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No....1. .�. .1L Fps........ y .......
THE COMMONWEALTH OF MASSACHUSETTS
i
BOARD OF HEALTH
..�� .............OF... .t� .!�'- �° ..
Appliratiou for Disposal Mirkstonstrurtion rrrmit
Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal
System at:
cation-Address or Lot No.
.._...... ...................................................... ................•-•---•-------------.........................----.................................
aOwner P Addres /�
a ►.�a...l✓.`^ l�A.----•--•......................................... .... `-Uti"u'+!u-�t��� ���t 4d�+�..... ���......
Installer Address `���
d Type of Building Size Lot...1 .,..'�C....'_':.Sq. feet
U Dwelling—No. of Bedrooms..........3...........................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons------------------=-------- Showers ( ) — Cafeteria ( )
a' Other fixtures -------------------------------- • _-
Design Flow--_-.•---------_-5-a .................gallons per .person per day. Total daily f1ow..S t®. A® _......gallons.
W 1
WSeptic Tank—Liquid capacity.[. :gallons Length__8_°.�___ Width__ �___�__ Diameter.-.-- _-___: Depth..S..a._.
x Disposal Trench—No. .................... Width-------------------- Total Length..................... Total leaching area------ __......sq. ft.
Seepage Pit No......A------------- Diameter.-_-:1.�:_�_..._. Depth below inlet_._3f5...... Total leaching area..�._n.....sq. ft.
Z Other Distribution box (x) Dosing tank ( )
~' �` � .... Date.__ !�
Percolation Test Results Performed by._��. �....................I� -....._..._ a3.1_..._ .....�...._...__....
,tea Test Pit No. 1-___�r.Zminutes per inch' Depth of Test Pit------ __....... Depth to ground water.__ — ----_--..
Test Pit No. 2................minutes per inch Depth of Test Pit------ ®...._... Depth to ground water...._R/ .........
Q+' ---------------------------------------------------------- [[ ----------------------•-•--------------•-••-----•-•-•-----------•--
0 Description of Soil............................ �_.....co`_A+-A _. & '��� L_
----------------------------------------------•----•--....:.........-•----._...--••
v ---.....-•-----•--••----------------------------------- 1 ........... =6`�---S== ----------------------------------------•-.....
w ................................................. ----------------------------------------------•----------------.....------....---------...--------------........------------=---------._-...........--
VNature of Repairs or Alterations—Answer when applicable....................................................:..........................................
--•-•----• --------------------------------•--------•••.....--•-•--•-----•---------••••-------......-•-•-------••--•----••••-•------••••---•••-•-•---••---••-•---••----•-••--•----------•-•--•------•---
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been 'ssued by the board of health.
Signed .............:.` .. . . ...................:. _ ..-.._............... ...:....------
Da[e
Application Approved By .............. --- ....... .. _e 7..
Application Disapproved for the ollowing reasons: . .......... . ................--....................----.:.....---..............................
t
Date
PermitNo. .......... � Issued ..............................................---....-----:.........
Dare
—————— ———————————— ----'---- — — ,:_.�.� - -- — --- —-----
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Fizz.... .. ...........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
a...i
.............OF...... .1�%S �- 7
Appliratiou for Disposal Works Ton,strurttnn rumit
Application is hereby made for a Permit to Construct (>') or Repair ( ) an Individual Sewage Disposal
System at:
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................0� :� ...................-C.':.....------�� r?- ....:�..... ..... --•-•--------•----------.. e-------------�?..[h��_„2s�.�,�? ----..
Location Address or Lot No.
......................_.......................................................................... -•---••---•-•------•--•-•......................_......._................._.............._..._.....
Owner r t Address
r �.
Installer r. r-.Address f
Type of Building Size Lot.__.C$a_q..____. ._.Sq. feet
,., Dwelling—No. of Bedrooms......... Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons---------------------------- Showe-s ( ) — Cafeteria ( )
as Other fixtures ............................_
---------------------------------------------------- ------•- •-••---•-•---•---•--•-•--•••-------
W Design Flow................ .................gallons per person per day. Total dailyflow.3X+'�v.-3..�!C?._......_.,_$?llons.
WSeptic Tank—Liquid capacity_ ?.gallons Length__&' .. p S__.�___. Width_.. .+_.__�_ Diameter................ De th_. ___.... -
x Disposal Trench—No. .................... Width.................... Total Length......_............. Total leaching area----
....-_ ft.
Seepage Pit No-------I .............. Diameter _ ..____ Depth below inlet.... .�:5........ Total leaching area... ......sq. ft.
Z Other Distribution box ()< ) Dosing tank ( )
~' Percolation Test Results Performed by- .!1,��� -_A.. __.__I+�:.............. Date_.Aj!......
:L ��. ...._.._......
Test Pit No. I.... -___��-._.minutes per inch Depth of Test Pit_....4.d._..___... Depth to ground water.._{) �....__._-_.
Test Pit No. 2.................minutes per inch Depth of Test Pit---A............. Depth to ground water----!�_��.........
a -------•---------------------- ----------------------------
0 Description of Soil.................••......- =+ c'�_.4,.k S[s— IsG_l L_
............ e.........................................G`'ah`"`'' ---------------------•--------------•---------------••-•---------•-.
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 TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has bee issued by the board of health.
Signed ..-- ....<..h", . ..................
----...__----------------- ---------------------------------------
....,t sj.. Date
Application Approved By ------------- ... .............-....-------
.---------------------------------------- ....... = e ....--. "t�
Application Disapproved for the�ollo�wing reasons: .......... . ....... ........................... .... . .......... . . ..... ...................... ..................
.....................................................�......................-- --............................... ..............................................---........................ ...--. ........................................
PermitNo. ...........,1 ...- . -Lf-. .... Issued .......................Dare.-....-...........-...........fe......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
&........ OF ............ -- --------------------------------------
Ger#tfirate of CLlampXianre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed) or Repaired ( )
by1 s s= �. �,._. ,,1 l'4t .�.'--. --- --------------------------------------------------------------------------------------------------------------------------
Installer
has been installed in accordance with the' r visions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. ...... - ...,-.:./....�/-.r .... dated ................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE........ A .---.. ........... . Inspect ............'
7- -
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�\
No... FEE....�r .t ......
Disposal Vorks Tnnotrnrtion "rrmit
Permissionis hereby granted..............................................................................................................................................
to Construct �Se) or Repair ( ) an Individual Sewage Disposal System
atNo.......,.,�. '" ...g........tl..i z .. �..�t(.........•. vL -----•-------•----------•--------------------------------
tree
as shown on the application for Disposal Works Construction Permit No. f � Dated_j!1-,�_ .'-. ........
( ........................................................................................
DATE........--/ •" Y
Board of Health
TM Form 1255 H&W HOBBS&WARREN Publishers
GENERAL NOTES : DESIGN CR 1 TER I A : JNVERT ELEVATIONS :
ACCESS COVERS MUST BE WITHIN
I. THIS PLAN !S FOR THE DESIGN AND
�a�.ou 12' OF FINISH GRADE DESIGN FLOW: INVERT AT BUILDING:
2
CONSTRUCTION OF THE SEWAGE DISPOSAL FIRST 2' TO BEDROOMS AT /0 G.P.D. PER INVERT IN SEPTIC TANK: _ 10 1-
SYS TEM ONLY.
BE LEVEL BEDROOM EQUALS . 'G. P. D. INVERT OUT SEPTIC TANK 101 i
4' Pvc INVERT IN DIST. BOX: I Go
SCHEDULE o a r,�-MIN` 2 or< A16 GARBAGE GRINDER INVERT OUT DIST. BOX:
2. ALL CONSTRUCTION METHODS AND PEAsroNE
O -195 °I'I�'
MATERIALS FOR THE SEPTIC SYSTEM m{ �""' INVERT IN LEACH PIT:
10l'S5� vcv.� 3/4' - I I/2" DIA. SEPTIC TANK REQUIRED:
SHALL CONFORM TO MASS. D. E. P. ,t
TITLE 5 AND LOCAL BOARD OF HEALTH ro. l {c,c,v - OUTLET ` -7,IV WASHED $TONE 7 GAL . BOTTOM OF LEACH PIT:
G.P.D. X l50x -
MIN. GAL D-Box , t ®� ADJUSTED GROUND WA TER:
SEPTIC TANK PROVIDED: .
REGULATIONS, sEPrlc TANK LEACH PIr OBSERVED GROUND WATER:
PROFILE : NOT TO SCALE SIZE OF LEACHING FACILITY REQUIRED:
J. ALL. SEPTIC SYSTEM COMPONENTS LOCATED UNDER AREAS SUBJECT TO VEHICULAR TRAFFIC G. P.D.
DESIGN PERC RATE - �"�' MIN/INCH
OR GREATER THAN 3 ' IN DEPTH SHALL BE
CAPABLE OF WITHSTANDING H-20 WHEEL LOADS. }-roo.a PROVIDED: PI T(S) W/ -S TN.
4. ALL SEWER PIPE SHALL BE SCHEDULE 40 SIDEWALL: S.F.X�,57 - 3e- GPD
OR APPROVED EQUAL . `� BOTTOM: S. F.X /,a _ /I.3 GPD
TOTAL : Z. `/S S.F. 4'13 GPD
5. BEFORE CONSTRUCTION CALL 'DIG-SAFE".
1-800-322-4844 FOR LOCATION OF `�\ �` &'�
SOIL TEST P I `T DA TA &
UNDERGROUND UTILITIES. Ce�y
�� FMB � \ 1 ND l CA TES ,�_ INDICATES
+103,4 \�` �\ lots ; PERCOLATION = OBSERVED
6. VERTICAL DATUM IS: ASSUMED .` `�` `
VEST _ GROUNDWATER
` �\, ZONE : RC; �`` TPA 1`Pw Z
7. FOR BENCH MARKS SET. SEE SITE PLAN. `+�'� ��� {3' �` SETBACKS: FRONT - 20 ' GRND EL. /d I GRND EL, U3•
t
,00 t /a?.r ��� \ SIDE - l0' G.W.EL, -PIA G.W.EL.
L0T 8
b�• t� \\� ��� \, REAR - !0 ' Lt>lt,.,o' 4 rat
15. 400# S.F. �,*.p �.
too.
t as.e
\` + \I V
tl 4* PIT rEsr HoLE' -
�� \` RESERVE 1 W/3'STONE
D-BOX {
+104.9
I000 GAL { TES t1LE L I bac�ta�hfiwt__ a, t ram .,eRA
SEPTIC TANK roa.s 1 t +100.4 -
26 DATE: 3//
las.ai
R°o ,� , ,.off TEST BY,
..� { tA i /
A.°° WITNESSED BY:
L1rEs -era \+ �0 1 So 1 �•t° / � PER RATE: MIN/INCH
t SEO � I /
t �+ / 6 �0ra
'+toy
it I t u, r
9.0
t '-� 1UP 938/0 S E P T / C S Y S T ErM D E_ S / ( /V
1 1 'off 1 .� MAILBOX nro a 94.4 / N
t'Z t` +to4,2 I `� ► A� —'f� .. TA R 4L jF . 0S TER V I I L ,'
+ j j I n } \{4• / CATOf BASIN
t t a-!F//,� r t I � i f
� PREPARE-L� FOR
AO
I t { °•15
MA RKW000 � oRP .
foils
J ,
tLBgctxX o.zt .Ni S C7A L E : / _ — 2 O APR / L -5 . / 9.9 4
1 /
!1 POLE
er
14 G L �" .S'UR YE'Y I NG' .�'NG I.IV�' '14 I NG . 1.V G" .
B t7 GB'I' C1t Cz1'2 B
~ !r<< t- `✓f ! HYD TAG NO.
ro4.1 . . ..� .� ?'a 4.42 2'
EL.- 104.40 .� 3 2 — .'J
CB/DtsK Pwo 104.4
0 10 20 _ _._40 [ JOB NO: 94-24I FIELD:CFW/RVB CALC: SAH CHECK: CFW =DRN., SAH