HomeMy WebLinkAbout0075 JOBY'S LANE - Health f 75 JOBYS;LANE, OSTERVILLE
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INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY /OM
LEACHING FACILITY: (type) 1�T (size) G X(a
NO. OF BEDROOMS a-
BUILDER OR OWNER SQJ A G VI-
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leachin facility) Feet
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Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Department of Environmental Protection
One Winter Street, Boston MA 02108 (617)292-5500
TRUDY COXE
Secretary
ARGEO PAUL CELLUCCI DAV[D B.STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 75 Jobys Lane, Osten4lle,MA Name of Owner: Sofia Giavis
Address of Owner:130 Raven Road
Date of Inspection: March 13, 2000 Lowell, MA 01852
Name of Inspector: (Please Print) James M.Ford
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) CPa:rcel.- 86
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 inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
✓ Passes
Conditionally Passes '
Needs Further Evaluation By the Local Approving Authority
_ ails
Inspector's Signature: Date: March 14, 2000
The System Inspector shall sub t a copy of this inspection report to the Approving Authority(Board of Health or DEP)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.
NOTES AND COMMENTS
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revised 9/2/98 Page,Iofll
Primed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 75 Jobys Lane, Ostemlle,MA
Owner: Sofia Giavis
Date of Inspection: March 13, 2000
INSPECTION SUMMARY: Check A, B, C, or D.
A. SYSTEM PASSES:
✓ I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 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.
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
Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or
the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
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,settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health)
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 pass
inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
revised 9/2/98 Page 2of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 75 Jobys Lurie, OstemUe, AM
Owner: Sofia Giavis r
Date of Inspection: March 13, 2000
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health,safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)
THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES
THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND
THE ENVIRONMENT:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet to a surface water supply or
tributary to a surface water supply.
The system has a septic tank and soil absorption system and the SAS is within a Zone 1 of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm. Method used to determine distance (approximation not valid).
3) OTHER
revised 9/2/98 Page 3of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 75 Jobys Lane, Osterville, AM
Owner:: Sofia Giavis
Date of Inspection: March 13, 2000
D. SYSTEM FAILS:
You must indicate either"Yes"or"No"as to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this
determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
Backup of sewage into facility or system component due to an 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 'h 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 Soil Absorption System,cesspool or privy is below the high groundwater elevation.
Any 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 1 of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for
coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS:
You must indicate either"Yes"or"No"as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public
health and safety and the environment because one or more of the following conditions exist:
Yes No
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 public
water supply well
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further information.
revised 9/2/98 Page 4of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 75 Jobys Lane, Osterville, MA
Owner: Sofia Giavis
Date of Inspection: March 13, 2000 3 ,
Check if the following have been done: You must indicate either"Yes"or"No" as to each of the following:
Yes No
✓ _ Pumping information was provided by the owner,occupant,or Board of Health.
*✓ 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. (*House was vacant)
✓ _ As built plans have been obtained and examined. Note if they aremot available with N/A.
✓ The facility or dwelling was inspected for signs of sewage back-up. FF-
✓ _ The system does not receive non-sanitary or industrial waste flow.
✓ _ The site was inspected for signs of breakout. ~
✓ _ All system components,excluding 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 conditions 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:
✓ _ Existing information. For example;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)].
✓ _ The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of
SubSurface Disposal Systems.
4
revised 9/2/98 Page 5of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 75 Jobys Lane, Osterville,MA
Owner: Sofia Giavis
Date of Inspection: March 13, 2000
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 110 g.p.d./bedroom.
Number of bedrooms(design): n/a Number of bedrooms(actual): 2
Total DESIGN flow n/a
Number of current residents: 0
Garbage grinder(yes or no): No
Laundry(separate system)(yes or no): No; If yes,separate inspection required
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings, if available(last two year's usage(gpd): 1999-1,000 gals.:1998-1,000 gals.
Sump Pump(yes or no): No
Last date of occupancy: Unknoym
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow: end(Based on 15.203)
Basis of design flow
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:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
None on file -per Treatment Plant
System pumped as part of inspection(yes or no): No
If yes,volume pumped: gallons
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)
I/A Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components,date installed(if known)and source of information: 1983-per as built card.
Sewage odors detected when arriving at the site: (yes or no) No
revised 9/2/98 Page 6of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 75 Jobys Lane, Osterville, M ,4
Owner: Sofia Giavis
Date of Inspection: March 13, 2000 ,
BUILDING SEWER:
(Locate on site plan) —
Depth below grade:
Material of construction: _cast iron _40 PVC _other(explain)
Distance from private water supply well or suction line
Diameter
Comments: (condition of joints, venting,evidence of leakage,etc.)
SEPTIC TANK: ✓
a
(locate on site plan)
Depth below grade: 18"
Material of construction: ✓concrete _metal _Fiberglass _Polyethylene _other(explain)
If tank is metal,list age_ Is age confirmed by Certificate of Compliance_(Yes/No)
Dimensions: 1000 gal.
Sludge depth: 0" -
Distance from top of sludge to bottom of outlet tee or baffle: 30"
Scum thickness: 0"
Distance from top of scum to top of outlet tee or baffle: 24"
Distance from bottom of scum to bottom of outlet tee or baffle: --
How dimensions were determined: Measuring stick
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.) The tee and baffle were present. There was no scum or solids in the system. The system was never really used.
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 baffle:
Date of last pumping:
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,stnictuml integrity,
evidence of leakage,etc.)
revised 9/2/98 Page 7of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 75 Jobys Lane, Ostert0e, MA
Owner: Sofia Giavis
Date of Inspection: March 13, 2000
TIGHT OR HOLDING TANK: None (Tank must be pumped prior to,or at time,of inspection)
(locate on site plan)
Depth below grade:
Material of construction: concrete metal —Polyethylene Fiber lass _other(explain)
g
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm present:
Alarm level: Alarm in working order: Yes_ No_
Date of previous pumping:
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
DISTRIBUTION BOX: ✓
(locate on site plan)
Depth of liquid level above outlet invert: --
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) The box was located, but not
dui2 up. There were no sig ms of failure in the pit.
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.)
revised 9/2/98 Page 8of11
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 75 Jobys Lane, Osterville,MA M
Owner: Sofia Giavis
Date of Inspection: March 13, 2000
SOIL ABSORPTION SYSTEM(SAS): ✓
(locate on site plan, if possible;excavation not required, location may be approximated by non-intrusive methods)
If not located,explain:
Type:
leaching pits,number: I-6'x 6'
leaching chambers, number:
leaching galleries,number:
leaching trenches,number, length:
leaching fields, number,dimensions:
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments:
(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.)
The pit was dry. There were no signs of failure. The bottom to grade was approx. 96".
CESSPOOLS: None
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow(cesspool must be pumped as part of inspection).
Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
PRIVY: None
(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.)
revised 9/2/98 Page 9of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 75 Jobys Lane, Ostemlle, MA
Owner: Sofia QaWs
Date of Inspection: March 13, 2000
Map. 120
Parcel. 86
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
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revised 9/2/98 Page 10of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 75 Jobys Lane, Osterville,MA
Owner: Sofia Giavis
Date of Inspection: March 13, 2000
NRCS Report name
Soil Type
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to Groundwater 25 Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observed Site(Abutting property,observation hole,basement sump etc.)
Determined from local conditions
✓ Checked with local Board of Health
Checked FEMA Maps
Checked pumping records
Check local excavators, installers
✓ Used USGS Data
Describe how you established the High Groundwater Elevation. @just be completed)
Using the Barnstable topographic and water contours maps, the maps were showing approximately 25' +/- to groundwater
at this site. Using the Cape Cod Commission Technical Bulletin, the high groundwater adjustment for this site(MI W 29,
Zone C, 2100)was 4.7'
This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty
or guarantee that the system will function property in the future. There have been no warranties or guarantees, either expressed,
written or implied, relating to the system, the inspection and/or this report.
revised 9/2/98 Page 11of11
• �•- Fss. �1l�
THE COMMONWEALTH OF MASSACHUSETTS
�-� BOARD OF HEALTH
1 . ............O F......1
�J plirFatiou for Bhipoii al ?forks Cna�a� uurtion amit
plication is hereby made for a Permit to Construct (/,<or Repair ( ) an Individual Sewage Disposal
stem at: _
_.. ------------------------------------- ------------.
Loca tion ress- ' Lot NOr
o.
s_.. �, --------------------------- _zz--lip ..... � . ...........
Owne --------------------------------Address
Installer Address
�. S
Q Type of Building Size Lot __.__.r._._. q. feet
Dwelling—No. of Bedroom_ s-------- --- ------------------------ -Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
a' Other fixtures -___._•____
W Design Flow.............. .....................gallons per person er,�ay. Total daily flow.___.__.....�...._...•...................gallons.
WSeptic Tank—Liquid capacity/ gallons Length_ a'.,__. Width................ Diameter---------------- Depth................
x Disposal Trench—No..................... Width,_.;_ Total Length..__:..........�� Total leaching area....................sq. ft.
Seepage Pit No._-__-___f.__.__.. Diameter./`'_.: __._._. Depth below inletZ. .0........ Total leaching area-Y�_-Xa24!Fsq. ft.
Z Other Distribution box ( ) Dosing an ( G - ,
Percolation Test Results Performed by--. 51--------------------------------- Date.: _ .....................�.
aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water-___•-_____-_-___-__-.
Test Pit No. 2................minutes per inch Depth of Test Pit___________________ Depth to ground water...................
OSoil � . ➢ - -- r--- �-7---1------------------- ------•---.:...
Description of ----- --..... ..........-------------�-`&1>.........J -�� ' .............x
U -----••--•-•--------•---------•-••••--•-••----•-•----------------------------------------------•--•••-•-•------------------•------........-------•-...................................................
W ---------------------------------------- •--•-•-•-------------•----•-•-••-•-•--...----------------------•------••----•-------------------------•-- .....................................................
U Nature of Repairs or Alterations—Answer when applicable_______________________________________________________________________________________________
-----------------------------------------------•-------------------------------------•---••-•---------.........-------------------------------------------------------------------•••-••---•--•--••....
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of 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 b the board of h th.
' Sig "' '� : �.._
..._ ..
ate
Application Approved By.ehe
._ .._..Y... _� _.....
Date
Application Disapproved fwing reasons:------------------------------------•------------------------•----------------------------Dat.e..............
-----------------•--------...---------••-------••-----••------------------------•---•----------------------••-•-----•---------•------••-----•--•-••-•-••-•••----••-•-•-----••••-------------.....---•--.
Date
PermitNo------.......................................................... Issued........................................................
Date
j
NoJ.,7..... �.... i Finis....._...............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....... � 41.........._OF.....-� .................................
A1111firation for BhipusFal Workii Tonotruriijan ramit
Oil
Application is hereby made for a Permit to Construct (PI or Repair ( ) an Individual Sewage Disposal
System at
.....4..t- ZZ.ir11_51.ji�/!..........4��....6rf ................................................ ...------------------------------
Location ress Lot No
� _. 7'-----------•------------ t , , . ------
Own� Address
-- f i-'....................................... ..................................................................................................
Installer Address
dType of Building Size Lot ...+,_ .Sq. feet
U Dwelling—No. of Bedrooms______________ _ __ __________________Expansion Attic ( ) Garbage Grinder ( )
pa, Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
Q, Other fixtures --- - ++�
W Design Flow____. ____: _ gallons per person er Jay. Total daily flow............................................� gal
�--� lons.
WSeptic Tank—Liquid capacity/ Length_ �7°r_._ Width---------------- Diameter_______________ Depth................
Disposal Trench—No_____________________ Width_ !,,'y_____ Total Length...... Total teaching area....---------------sq. ft.
Seepage Pit No__________ _______ Diameter_ _ft'�t_.__._._ Depth below inlet _`r .'� . Total leaching areaAssq..ft.
Z Other Distribution box ( ) Dosing tin
Percolation Test Results Performed by _.....•-----•-••------•••--_. Date__/ .............� *
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water-------:.............__.
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
,�
-
0 Description of Soil...... _ .... __ . .. ____
- ............
x
W -------•-•-------------------- -------•-----••-••-•••-•-••••--------•---•-------•'-•••----•--...-••---•--••--•---------•••-----•••--••••-•-----•------•-•-•--••--••••••--••••-•--•••••---....________•-
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 b the board of h th
- Sig ---•-•�°� -- �•" "'"'-je --- ---- ---- - -------=-------•---•--- --leg ��.-•-
to
Application Approved BY_ .. Date
A
pplication Disapproved for a following reasons:......................................................................=.........................................
------------------------•....-•--•--•-•--------------•--•----•---••---•-•....•---•---------•---•----•••--•----•-•---•----•-•----••••--------•--•------•----------------- ........ ......................
Date
PermitNo......................................................... Issued_.......................................................
Date
i
THE COMMONWEALTH OF MASSACHUSETTS
i
BOARD OF HEALTH
.......149> ............OF....... ' ',rC.?...... .........................
Trtif iratr of hum �i�aiar
YJIS 0 CE TIFY, T at the Individual Sewage Disposal System constructed ( ) or Repairedby..... ?. 1 .................... A...-.-------••----•------- -------------------•--•---..._.._...._..-••--••-••--•------•---•-••••-------...._
'""" j Installer
at..... d'_ ............`�� _± .e` _.•_ ...?�e ...__. .',� ----'Z.t F - -•-•---------- ---------•---in the
application for Disposal Works Construction Permit No.-_l.+_.J."__ �•_______________ da.ted_.-._ __ - .___.__.___.________
THE ISSUANCE OF THIS CERTIFICATE SHALL NOTBE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector.....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEALTH
No._. ._._ ..... FEE....................•---
�nt!'.7_10CXX..
�Permission is hereby ` . ... - .._...
to Construct ( r Rfe air ( ) an Individual wage Disposal System
atNo..... ' + �!_, _.. _.._. Lit 1-k........................................................................................................
Street
as shown o/the licat•on for Disposal Works Construction Permit No.................. ... '.r__ _.::..._____._....
....................................... - `--` ....................................
and of Health
DATE_ �,3--•---•---•---•---•--•-••----•--•-•----•--.._.....
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS
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EXISTING SPOT ELEVATI N 0 0' ��� Hof
EXISTING CONTOUR --- O --- y Z 17 J0, is Z-4
FINISHED SPOT ELEV ION Aug �,v , .� 7` f ��' ✓< ;._e. r
FINISHED CONTOUR ® o
� IN
APPROVED , BOARD OF HEALTH No.10951 q
A90 FG/s-r :
FF'T/0NAL
DATE ANENT SCALES - `fir DATE , /0 ji �
: .LDREDGE ENGINEERING Cat IN CLIENT � '3�� I CERTIFY THAT THE PROPOSED
EGISTERE REGISTMED JOB NO. 80051._ BUILDING SHOWN ON THIS PLAN
LCIVIL LAND CONFORMS TO THE ZONING LAWS
'ENGINEER URVEY R DR.By 4A OF ®ARNS.TA E , ,ASS.
712 MAIN STREET CM. 13Y cl.T�'•C• �' ?..,
. H Y A N N I $, MASS.. � l0 22 e2 �-=---,- .`__. .
SHEET_L OF DATE tfG. . LAND SURVEYOR
20 FT M/A/. /1l07E /F E/TNER THE SEPTIC TANK O
R
Ei4CN//vG P/T ,4,vzr MORE THAN'/ /2BELOyV
SRAOE, Al 24 �VIAM E7 C'Oi1/CR it COVER
Sl/ALL eF ,9ROU(SHT To GRAO,E. �.-r,v EX7,?A
CONCRETE 4�PYC P/Pt �E,gYy cA S T /RON Co{iEi?. SN�4G L 3E USEL7
M/N. P/TCN
CL =/, l v •:� GOYERS. - �B PFR FT /F/'IV OR/VEWA Y
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CU ✓E CLEAN -FA NO I
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INYE .R.T AT OU/LD/NG /O/,O FT 6 D/AM. t
INLET SEPT/C Ti4NK !o�• FT. !D FT O/AM. a.? C SEE TABULATION
OUTLET SEPTIC TANK
INLET`DIS7,,T., / >y BOX l�� FT. SECTOON OF GRO/JNO iV EJe 7i4eLE
0VrLETb/37R/BtrTI01V BOX /U0•Z FT
/NCET..LPACNINS'4c=/7" o¢.Q FT. .SELVAGE O/SPdSA L SYSTEM
LEACH//V�s 40/7' TABULATION
SCALE. : %s. _ /=Q� D/MEN.S/D At A 3 FT.
DES/G'IY CR/TER/A
NUMBER OF BEORaOMS 3 D/MENS/O/1� c; FT. M t /.
G.+RQ,4GEQ/sPos.�L uv/r �oa� SO/L LOG
TOTAL,EST/^%4reL) FLOW 3 3 G.4L.�DAY SO`%L TEST lit/ SOIL TEST 2 SD/L
NUMBER OF L,CS4cK/NG ,o/%S L_ f-ECEK �a z ° � . g 3T
S/OF L,EACH//V¢ PER R17' PT. ' RESULTS W/T/VESSED BY
B T M OTO tEACNN/ G PER P/T 7 so. Fr. 0 ��,*i �' PER COL AT/ON RAT&At LEss II/vl1NCH . -
TOTAL LEACH/1V6 AREA Z� SQ. FT. ��/1�SO 1/ AFit COLA T/o/V RATE 1EE 2 7"rf.4'�/y1 N.l/NCH
,IT RE. ERV-6 ZEAC N A 6 AREA z_(, SQ F T. z,a
OF
1' No.10951 q
EL DREDGE ENGINEERING CO /IVC•
7/2 M/1/N ST. HY.q/t/N/S. INASS;
% Dsu E) NO Cr T0V/V0 YVAr,&M ENCOU/VTLE'REO C,4AF"r: l e;11410
�� Q GROU/V,0 YVATE.P AT ELEf/.
J08 I 6CX�5 SHEET OF