HomeMy WebLinkAbout0120 SETH GOODSPEED'S WAY - Health 120 Seth Goodspee,%V �
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Osterville
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f
TOWN OF BARNSTABLE
LO TION �, SEWAGE#
VILL GE �-p��(`�a�Gt 2 ASSESSOR'S MAP&P RCEL
INSTALLERS NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY.-(type) �'e -fij (size) / i>✓T C
NO.OF BEDROOMS
OWNER
PERMIT DATE: CO PLIANCE DATE: ,r
Separation Distance Between t e: f-c-- L rC C—
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
tf
LA
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_3 t o
Y
�-No. Fee 00
THE COMMONWEALTH OF'MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
01pprication for �Digoal *paem Cou5truction Permit
Application for a Permit to Constru t( ) Repair Upgrade( ) Abandon( ) Complete System❑Individual Components
Location Address or Lot No. V e 6w-o S $C , is Name,Address,and Tel.No. 4w,;t.f',
Assessor's Ma /Parcel c DrV 'e �LO ✓ Bade @+�G
p Q—
Installer's Name,Address,and Tel.No. J��S�� A �� esigner's Name,Address and Tel.No. lvC-1 O*e
Type of Building:
Dwelling No.of Bedrooms ? Ct Lot Size sq. ft. Garbage Grinder ( )
Other Type of Building J No.of Persons Showers( ) Cafeteria( )
Other Fixtures '
Design Flow(min.required) 33CI gpd Design flow provided `7,2 •�`r gpd
Plan Date!/ Number of sheets Revision Date
Title
Size of Septic Tank /51rd Type of S.A.S.
Description of Soil .S.e.... [ O!;
Nature of Repairs or Alterations(Answer when applicable) a '?` ���GV
4 / r
I
Date last inspected: M US
Agreement: 3
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal syYm m
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Hi lth.
Signed Date ZQ
Application Approved by A 0 Date
Application Disapproved by. Date
for the following reasons
Permit No. Q I' ——————————Date Issued
------------ — _ __ ___— --__--- ----- -- - - - -
1
No. c/ U I I n. Fee /v o —
( -�%
f
THE COMMONWEALTH OPMASSACHUSETTS Entered in computer:
PUBLIC-HEALTH DIVISION - TOWN OF B�ARNSTABLE, MASSACHUSETTS Yes
2pplication for Oigogal �&potem Construction Permit
Application for a Permit toCois� ( ) Repair Upgrade( ) Abandon( ) Complete System ❑Individual Components
�7
•
Location Address or Lot No. E / G G o C S�C c CC f�(// 'O�4er's Name,Address,and Tel.No. i (� /w/(',"I�l
O / �
Assessor's Map/Parcel / z / OS f ` IL U ✓ e /�'� GO O�5��
Installer's Name,Address,and Tel.No. J G S o� 'SCV -D se igner's Name,Address and Tel.No.
-. Type of Building:
Dwelling No.of Bedrooms / ✓c l/i� Lot Size o?y.(>iD`j sq. It Garbage Grinder ( )
Other Type of Building .� No.of Persons Showers Ca
feteria(
ena
YP g ( ) ( )
�y Other Fixtures
Design Flow(min.required) 33ey gpd Design flow provided �/ -25- gpd
Plan Date 31 3 / 1// Number of sheets Revision Date
Title
Size of Septic Tank /,Ss p Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) �}C�r�a "T j ('/)/ GtU 4 G t
Date last inspected: M uJ �If / J
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 Certificate of
Compliance has been issued by this Board of He��lth.
Signed ` � Date < < 2 �
Application Approved by t Date L /
Application Disapproved by. Date
for the following reasons
Permit No. Date Issued /
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of (Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed Repaired �Upgraded
g P Y ( ) P ( ) ( )
Abandoned( )by �G S S� .
at I Z J Se �� �- c �A� o/ has been constructed in accordance
with the,provisions of Title 5-and the for Disposal System Construction Permit No. dated Z
Installer `" Designer
#bedrooms ?J Approved design flow �_ 3 CJ gpd
The iss ce of this pe <shall not e co st)rued as a guarantee that the system will fiinction�as`designed.
Date ! Z t // Inspector 1
No. a— Fee Ay) '~
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION — BARNSTABLE, MASSACHUSETTS
x1i5poal *P!5tem Construction 'Permit
Permission is hereby granted to Construct ( ) Repair ( ) Upgrade ( ) Abandon ( )
System located at
r
i
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty
to comply with Title 5 and the following local provisions or special conditions.
Provided: Construction ust be completed within three years of the date of thieT)t.
Date a Approved by
VPA
T -6 1C mvf P-f rr�
Town of Barnstable
'"E'' Regulatory Services
Thomas F. Geiler, Director
• snansrnUZ +
MAn
1679� Public Health Division
�p �0
Thomas McKean, Director
— 200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer & Designer Certification Form
Date: i Sewage Permit# 0?0// ZZAssessor's Map\Parcel
Designer: Installer: . - ov-cc_
Address: 6 0 k_ Address: o? l aUn'f L-J LZ o .
On was issued a permit to install a
(date) (Installer) �,,
septic system at h G� V V� based on a design drawn by
�� A /(address)
dated
(designer)
I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box andi'or septic tank.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or anv vertical relocation of any component
of the septic system) but in abcordance with State & Local Regulations. Plan revision or
certified as-built by designer'to follow.
OF MgS�9c
y�
t �R
7(1r s Signatur ` No: 1140
SI SOI1WP�
(Designer's Signature) l/ (Affix Designer's Stamp Here)
PLEASE RETURN TO BA TABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF
COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE
RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU.
Q: Health/Septic/Designer Certification Form 3-26-04:1doc
i
Town of B -nStable. P# a 2
of THE -
Departm,Pnt of Re�atory Services
-Public Health Division' Date 3
- s6J9 tee$ 200 Main Street,Hyannis MA 02601.
00
Date Scheduled i Time Fee Pd.
_ e
$o l-Suitab4io Assess mnent'for rSejvctge Disposal.
- Performed By: �' Y ;r�.'✓� , ' l tG' (' . Witnessed By:
i
LOCATION & GENERAL INFORMATION
Location Address'• 2 o S Owner's Name A-P1' ,l NE ' .DO��.
S edD 6 w�ny I Zo Serk 6W os�P
i Ite /Vb9 j ddrecs lK*, -vi'/l C ,Mt,
Assessor's Map/P4rcel:- ? �/ I" Engineer's Name_Pa ryc� M evr
NEWCONSIRUTION REPAIR Telephone#�DtC 36Z- 2�LZ
�j 1'CC�.�^�lC �. - Surface Stones
Land Use ,Slopes(9'0) t '
Distances from: Open Water Body ft Possible Wee Area ft .Drinking Water Well � e ft ,
, a
Drainage Way . it Property Line ��C) ft Othei ft
SKETCH:(street name,dimensions of lot,exact locations of te§t holes&perc tests,I- Ptlands in proximity to holes)
ir�s, moo -y, .. •
.. _j,� 1 WOODED `
• t OP
• 't' '� 0 L-'JL 1t•�
O..
(Z.- v1 \0
`•.. Sy9ti5 SHED i ' _L;
w--�--�,
�y "O PARCEL ID for 60�3Or TANK _
t y UCpLE 122/091 - EL= 4
"'••, _ AREM20.609t SY. 1
�A �1 - #120
< \\ - ;:3-BEDROOM,
_ A I v - DWELLING
0 m I •W 1,11 0R CONL PAD Z
.W� TOF-6270
pSPMA�y~ _ WOODED', ,..
•1 0R1�1' t i '
-------------------
- Z N99'24'10"E 154.03' -
Parent material(geologic) r ' je Depth to Bt:ilrock
• Weeping from Pit
Depth to Groundwakdr. Standing Water in Hole: i p• g Face.
Estimated Seasonal14igb Groundwater
n DtTERMINATION FOR SEAS ONAL HIGH WA'�T TABLE
Method Used: I '
Depth Qbperved standing in obs.hole: in. .Depth.io soil mottles: In.
Depth toiweeping from'side of obs.hole: ` in. Oioundwnter Adjustment , .
Index Well# Reading Date: v Index Well level � Adj.Actor Adj.C7►Gundwtlter Level.,�e
i
PERCOLATYbN—,T +'ST . Ddte -Tlme—.
Observation _ Time at 9"
Hole#
y Time a[G';
i Depth of Pere
Start Pre-soak Time:@
End Pre-soak
Rate Min-/Inch
-
Site Suitability Assessment: Site Passed Additional Testing Needed(YIN)Site Failed; - ,
Original.Publicle'ilth Division Observation Hole Data To Be Completed on Back--***If percola>ion test is to be condTacted within I00' of wetland,you must first notify the
Barnstable Cdriservation Division at least one (I) weak prior to beginning.
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Sail Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistenc %Gravel
�G 132± 5 Z S J/
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color ,Soil Other
Mottling`-`(Structure,Stones,Boulders.
Surface(in.) (USDA) (Hansel;}
Consistency.°%Gravel)
AA AA
Ay
r10
DEEP OBSERVATION HOLE LOG. Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency,%Gravel
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency, Gravel)
Flood Insurance Rate Map: a
Above 500 year flood boundary No Yes
Within 500 year boundary rY No Yes
Within 100 year flood boundary No_ Yes
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring perv' s material exist.in all areas observed throughout the
area proposed for the soil absorption system?
If not, what is the depth of naturally occurring pervious material?
Certification �.4.
I certify that on (date)I have passed the soil evaluator examination approved by the
Department of Environ ental Protection and that the above analysis was performed by me consistent with
the require ing,expertise and experience described in 3.10 CMR 15.017.
Signature tAA r� Date yl ll
0ASEPTIC\PERCFORM.DOC
ft. - ---
'T 61
1 J
1'
Nr i_.- SEPTIC SYSTEM IS DRAWN PER
TC `!I.i OF BARNSTABLE AS—BUILT CARD.
SHED
i cn
� o
1 5.6 f t
w
LOT 60 o
20608.4 SO. Ff. m
O oo 0.47 ACRES
r 00
DECK -
120 --- -- �4.7ft o
a_
68
- 713
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COMMONWEALTH OF MASSACIIUSETTS
- Exi-i=TIVE OFFICE, ENVIRONMENTAL A F 8
llEPARTUENT OF ENVIIZONMEN 1'AL PROTh
` ONE WINTER STREET, BOS'T'ON MA 02108 (617) 292-55
350 MAIN STREET A A 7
gTR coxe
WEST YARMOUTH, MA jgg
ti cretary
508-775-2800 pNOF
ARGEO PAUL CELLUCCI � ftawuAVID TRUIIS
Governor onr uIssioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FO W q
PART A
CERTIFICATION
MAP 122 PAR 091
PROPERTY ADDRESS: 120 SETH GOODSPEED.WAY,-OSTERVILLE ADDRESS OF OWNER:
DATE OF INSPECTION: APRIL 14, 1999 VIVIAN KALLENBERG
NAME OF INSPECTOR : JAMES D. SEARS
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 9310 CMR 15.000)
COMPANY NAME: A&B Canco
MAILING ADDRESS: 350 Main Street,West Yarmouth,MA 02673
TELEPHONE NUMBER: (508)775-2800 a
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:
X PASSES
CONDITIONALLY PASSES
NEEDS FURTHER EVALUATION BY THE LOCAL APPROVING AUTHORITY
FAILS
INSPECTORS SIGNATURE: "
DATE: APRIL21,1999
The system Inspector shall submit 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:
NOTE: SYSTEM IS OVER 20 YEARS OLD, LITTLE USAGE AND SEASONAL. ANY CHANGE IN USAGE MAY
OVERLOAD THE SYSTEM.
}
SITE OVER ALL PASSES,INSPECTION OF SYSTEM IS BASED ON CONDITION OF,SYSTEM AT THE TIME
OF THE INSPECTION.THERE IS NO GUARANTEE ON THE LIFE OF THE SYSTEM.
.n
revised 9/2/98
SUBSURFACE SEWAGE,DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIVICATION (continued)
Property Address: 120 SETH GOODSPEED WAY,OSTERVILLE`'= ,
Owner: KALLENBERG,VIVIAN
Date of Inspection: APRIL 14, 1999 `
INSPECTION SUMMARY: Check A, B, C„orD:
A] SYSTEM PASSES: X
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR
15.303. Any failure criteria not evaluated are indicated below. `(
COMMENTS:
B SYSTEM CONDITIONALLY PASSES: N/A
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 is failure is imminent. The system will pass inspection if the existing septic tank is replaced with a
conforming septic tank as approved by the Board of Health.
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 pa
pass inspection if(with approval of the Board of Health).
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
_ The system required pumping more than four times.a year due to broken or obstructed
pipe(s). The system will pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced.
obstruction is removed
revised 9/2/98 2
r—
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
"PART A
CERTIFICATION(continued)
Property Address: 120 SETH GOODSPEED WAY, OSTERVILLE
Owner: KALLENBERG,VIVIAN
Date of Inspection: APRIL 14, 1999
C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: 'N/A
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)THT 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 of 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 and is equal to or less than 5 ppm. Method
used to determine distance (approximation not valid).
3) OTHER +,
i
revised 9/2/98 3 j
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 120 SETH GOODSPEED WAY, OSTERVILLE,
Owner: KALLENBERG,VIVIAN
Date of Inspection: APRIL 14, 1999 '
D] SYSTEM FAILS: N/A
You must indicate either"Yes"or"No to each of the following: `
I have determined that one or more of the following failure conditions exist as described in 310 CMR
16.303. 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 over-
loaded 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%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 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. 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: N/A
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
mapped Zone 11 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. rP .y.
F
, S
revised 9/2/98 . .4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 120 SETH GOODSPEED WAY, OSTERVILLE ,
Owner: KALLENBERG,VIVIAN,
Date of Inspection: APRIL 14, 1999
L
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
j"
Yes No
N/A Pumping information was provided by the owner,occupant,or Board of Health.
X None of the system components have been pumped for at least two weeks and the system
has not been receiving normal flow rates during that period. Large volumes of water have not been introduced
into the system recently or as part of this inspection.
X As built plans have been obtained and examined. Note if they are not available with N/A.
X The facility or dwelling was inspected for signs of sewage back-up.
X The system does not receive non-sanitary or industrial waste flow.
X The site was inspected for signs of breakout.
X All system components,including the Soil Absorption System,have been located on the site.
X The septic tank manholes were uncovered,opened,and the interior of the septic tank was
inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid
depth of sludge,depth of scum. The size and location of the Soil Absorption System on the site
Has been determined based on: ,
X Existing information.Ex.Plan at B.O.H. G
X Determined in the field(if any of the failure criteria related to'PartC'is at issue;approximation
of distance is unacceptable)115.302(3)(b)] T
X The facility owner(and occupants,if different from owner)were provided with information on
the proper maintenance of Sub-Surface Disposal System.
revised 9/2/98 5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 120 SETH GOODSPEED WAY, OSTERVILLE
Owner: KALLENBERG,VIVIAN
Date of Inspection: APRIL 14, 1999.
FLOW CONDITIONS
• v
RESIDENTIAL: r
Design flow: 330 g.p.d./bedroom for S.A.S.
Number of bedrooms(design) 3 Number of bedrooms(actual): 3 "
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): YES
Seasonal use(yes or no) YES
Water meter readings,if available(last two(2)year usage(gpd): 1997 55,000/1998 54,000
Sump Pump(yes or no): NO
Last date of occupancy: N/A
CO M M ERCIAL/I N DUSTRIAL: .
Type of establishment:
Design flow: Gpd(Based on 16.203)
Basis of design flow k
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:
,a.
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
N/A
System pumped as part of inspection:(yes or no) NO
If yes,volume pumped: Gallons
Reason for pumping
TYPE OF SYSTEM '
X Septic tank/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:
1977 PERMIT#77-213 -
Sewage odors detected when arriving at the site:(yes or no) NO
revised 9/2/98 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 120 SETH GOODSPEED WAY, OSTERVILLE a
Owner: KALLENBERG,VIVIAN ;
Date of Inspection: APRIL 14, 1999 -
BUILDING SEWER: N/A
(Locate on site plan)
Depth below grade: m Art
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: X F
(Locate on site plan) s
Depth below grade: 10"
Material of construction X concrete _ metal . _ Fiberglass ''Polyethylene other(explain)
If tank is metal,list age Is age confirmed by Certificate of Compliance - (Yes/No)
Dimensions: 1 OOO GALLON
Sludge depth: 2" _
Distance from top of sludge to bottom_ of outlet tee or baffle: 28"
Scum thickness: 0"
Distance from top of scum to top of outlet tee or baffle: 12"
Distance from bottom of scum to bottom of outlet tee or baffle: 18
How dimensions were determined ASBUILT AND TAPE
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.)
TANK AT WORKING LEVEL,OUTLET BAFFLE TANK AND COVERS 10"BELOW GRADE.
GREASE TRAP: N/A
(locate on site plan)
Depth below grade:
Material of construction concrete _ metal _ Fiberglass, = Polyethylene other(explain)
77
_ .
Dimensions: r
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,structural
integrity,evidence of leakage,etc.)
revised 9/2/98 , 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 120 SETH GOODSPEED WAY, OSTERVILLE
Owner: KALLENBERG,VIVIAN
Date of Inspection: APRIL 14, 1999
TIGHT OR HOLDING TANK: NIA (Tank must be pumped prior to,or at time,of.inspection)
(Locate on site plan)
Depth below grade: c _
Material of construction _ concrete _ metal 'Fiberglass Polyethylene _ other(explain)
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: N/A
(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,) ,
PUMP CHAMBER: N/A
(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.) �&
a
revised 9/2/98 8 _ :
SUBSURFACE:SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)-
Property Address: 120 SETH GOODSPEED WAY, OSTERVILLE
Owner: KALLENBERG, VIVIAN
Date of Inspection: APRIL 14, 1999 F'
z
SOIL ABSORPTION SYSTEM (SAS): X
(locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods).
If not located, explain: '
i .
•
I
Type:
Leaching pits,number. 1
Leaching chambers,number:
Leaching galleries,number. "
Leaching trenches,number,length:
Leaching fields,number,dimensions: '
Overflow cesspool,number,
Alternative system:
Name of Technology:
Comments: s�
(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.)
ONE(1)1,000 GALLON PRE CAST PIT,PIT DRY SOME ROOTS ON WALLS.PIT AND COVER 2'BELOW GRADE.
CESSPOOLS: N/A
(locate on site plan) "
Number and configuration:'
Depth-top of liquid to inlet invert:
Depth of solids layer: ti �•`'
Depth of scum layer.
Dimensions of cesspool: 3
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: N/A
(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.)
r _
°
revised 9/2/98 9
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued).
Property Address: 120 SETH GOODSPEED WAY, OSTERVILLE
Owner: KALLENBERG, VIVIAN r R
Date of Inspection: -APRIL 14, 1999
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'(locate where,public water supply comes into house)+.
- -
/Q £AR
33 1
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revised 9/2/98 ^ 10,
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C t
SYSTEM INFORMATION(continued)
Property Address: 120 SETH GOODSPEED WAY, OSTERVILLE =
Owner: KALLENBERG, VIVIAN
Date of Inspection: APRIL 14, 1999
NRCS Report name
Soil Type
Typical depth to groundwater.
USGS Date website visited
Observation Wells checked
Ground water depth: Shallow Moderate Deep
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to no groundwater' 11� Feet + =J
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
X Observation of Site(Abutting property,observation hole,basement sump etc.)
Determine it from local conditions
Check with local Board of health t ,
Check FEMA Maps
Check pumping records . .N
4
Check local excavators,installers
Use USGS Data 1
Describe in your own words how you established the High Groundwater Elevation.(Must be completed) .. .s
NOTE: HAND DUG TEST HOLE, NO WATER AT 11'. TEST HOLE T BELOW BOTTOM OF PIT.
revised 9/2/98 11
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LO=CATION SEWAGE PERMIT NO.
0 S .4 .laa-11�
VILLAGE
INSTALLER'S NA E & ADDRESS
B U I'L D E R OR OWNER
DATE PERMIT ISSUED 1110
DATE COMPLIANCE ISSUED
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No.. ... Fps. ..........................
THE COMMONWEALTH OF MASSACHUSETTS
-7,-- BOARD OF M V
0 F. .. . _ _.- o...... .........
Apphration -for 43itipmal Workii Totu4rurfiott Prrutit
Application is hereby*made for a Permit to Construct )' Repair an Individual Sewage Disposal
Syst V. a
.... .. ............... -'Address". ......... ................ or Lot.Ito.
.......................................
... .... ..... ----------- .................. ---
ow Add
. .......iXl.�_Z,r; Address
Type of Building Size Lot... ------ 5Sq. feet
- ---
U
Dwelling—No. of Bedrooms....... -----------------------------Expansion Attic Garbage Grinder
�4
a4 Other—Type of Building ---------------------------- No. of persons......_...._....._._..___.._ Showers Cafeteria
Otherfixtures ........ -------------- --------------------------------------------------------- ---------------------------
W Design Flow............5 ----_----------------gallons per pet-son per day. Total daily flow................. a............gallons.
WSeptic Tank—Liquid capacit/0" 'gallons Length________________ Width................ Diameter_............... Depth----------------
Disposal Trench—No..................... W* .................... To ength-----------0� Tot caching area-..--.-.---_.-----sq. f t.
Seepage Pit No.-Z............... ------------------ EM64r~ei iOP-ele-it---------- o a leachin area,�;.9: -'-sq. ft.
, L 9
Z Other Distribution box Dosing tank
Percolation Test Results Performed by--------------------------------------------------------------------------- Date---------------------------------------
Test Pit No. 1_-------------minutesperinch Depth of Test Pit--------------------- Depth to-ground water....-.---.--.--.-----_.
�, Test Pit No. 2----------------minutes per inch Depth of Test Pit_.._.._...___...__._ Depth to ground water-..--..--__---..----.---
a ----------------------------------- ----------
Description of Soil
J. -2-i......
Z ------------------
v ._.._-------• _&------
------------------ -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
U Nature of Repairs or Alterations--Answer when applicable---------------__------------------------------------------------------ --------------------
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Agreement:
The undersigned agrees to. install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate o;fCornLpliance has been issued b h b d f h h S is �y e 47 o ea k -
Sign ign ..... ....... ............................... ....... ..
S,
..........�ot-f;
Application Approved By----- ........ .. -- -----------
Date
Application Disapproved for the following reasons:................................................................................................................
..............................................................................................---------------------------------------------------------------------7------------------------------------
Date
PermitNo......................................................... Issued.......................................................
Date
-------------
No.......�9/2....... . .......................
THE COMMONWEALTH OF MASSACHUSETTS
--�-- BOARDpOF HEALTH
h:
. lire#itin -for Ditivogat Workii Cnonfitrurtion Prruid
Application is hereby made for a Permit to Construct (�" ) or Repair ( } an Individual Sewage Disposal
System at'.
--✓-/ . - � of/G'''�
- ' ------------------ -- ............................................................................................Location-Address +�` f / < or Lot No.
r i .. ...E��/..
07 / Address f
..........................................................
� Installer /-,f Address '
Type of Building Size Lot... -------�_-d-5;..Sq. feet
Dwelling—No. of Bedrooms---- --------------------------_-.Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons._----_----_______--_-____ Showers ( ) — Cafeteria ( )
d Other fixtures . -r-c - --- -------------------- ---------------------
W
Design Flow___........_``... .....................gallons per person per day. Total daily flow---------------- ----------._gallons.
WSeptic Tank=Liquid capacit/ allons Length---------------- Width---------------- Diameter................ Depth................
x Disposal Trench—No- ___________________ Width-----------_------ Total Length------------------- `Total'leaching area--------------------sq. ft.
Seepage Pit No..f.!rd.'1--- Diamete�� _--- Depth-below inlet-- otal leaching area------------_sq. ft. -
Z Other Distribution box ( )f Dosing tank ( ) —0 js.Ar/,&- 1!«//- 77r
~" Percolation Test Results Performed by-------------------------------------------------------------------------- Date-_-----.--------------..---------------.
W
HTes Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water.__---._.--_-..-__.____.
rxq Test.Pit No. 2----------------minutes per inch Depth of Test Pit__..--_-__-___-___- Depth to ground water......----_-_-_.______-
�+ ..................
Description of Soll f� �F/
w
------------- ------ ---
U Nature of Repairs or Alterations—Answer when applicable-------------___------------------------------------------------------------------- ------------
---------------------------
------------m
Agreement
The undersigned agrees"to.install't' e aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the'State Sanitary Code—The undersigned further agrees not to place the system iii.
operation until a Certificate of'Compliance has been issued by the board of health. 1
f,
Sign - ---- - - - -- s -
f �,rf /Date
Application Approved B b /'`
O -# --------
IV I Date
Application Disapproved for the following reasons:-._-•-----------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------
Date
PermitNo..............------ ••-•••-••-•--•---•--......._. Issued--------------------------- =--------------------------
Date
r
THE COMMONWEALTH OF MASSACHUSETTS
_.. BOARD OF HEALTH
14.
............ .. ., . ,1.a..,,:....OF.....
........................................................
.r01rdifirtttr of T>ormphaurr
"THIS IS TO CERTIFY, That/the Individual Sewage Disposal System constructed (� ) or Repaired ( )
by .............................................
y — Insta � f '
G'
r
--------------
has been installed in accordance with the provisions of Ar XI of The�State Sanitary Code as described in the
application for Disposal Works Construction Permit No ; . ------------ dated----. -7------------ -•---
THE ISSUANCE OF THIS CERTIFId'ili SHALL. NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WI FUNCTION SATISFACTORY
d A /
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DATE .F r=!f*.'?"::..... . ---- ° ! =�r�.r'' Ins ector i........`
P - .. � v. ------------••-•------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF 1EA11H
fJ
No........�...„ -- . - FEE........................
�i����tti, rrrk,� C�>att�#r�tr�il�ig �rr�tit
Permission is hereby granted. ' ---`--------------- --•--•.... ...'......----=------------....------------...-------------------------•--••-
to Construct ( r) or Repair ( ) a(Individual Sewage Disposal System ! A
atNo. -------••--•---••-----•--•-•--•---•••............................
/ Street
as shown on the application for Disposal Works Construction P it N _ _____________ Dated___ " -� �`_ ...........
oar of Health
DATE................................................................................
FORM 1255 HOBBS':&.WARREN. INC.. PUBLISHERS -
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PARCEL ID:
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PROP. 1500G '�• °°' Qf
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SEPTIC TANK
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N PARCEL ID: 120 SETH
122/092 -50 � WOODED GOODSPEED'S
1�� o WAY
r ROUTE 28
N� 0
EXIST. 19000G
SEPTIC TANK . A. l LOCUS MAP
��. LOCUS INFORMATION
TH—1 z
PLAN REF: 311/77
p�1 cps TITLE REF: 13533/281
PARCEL ID: MAP 122 PAR. 91
Sg9 SHE i cn IN ZONE II
( TUh P FLOOD ZONE: "C"
TH-2 0 COMMUNITY PANEL: 250001-001 5-C DATED:08/19/85
30.90
TWI PARCEL ID: SEPTIC SYSTEM
/077.
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146 REPAIR PLAN
LOCATED AT:
uTIL. cps PARCEL ID: TOP 0r TANK Exist. Leach Pit 120 SETH GOODSPEED'S WAY
[� UPQLE 122/091 EL=60.�4 (see note 10) OSTER VI LLE, MA.
\ AREA=20,609t S.F.'
/ #120 �� o p PREPARED FOR
3-BEDROOM k 00
N W�, ARLINE DOHERTY
-)3 I DWELLING ; �� -• � �
��`� `�\'' i ' ►� PwQca � _._..i' . j MARCH 31, 2011
Q �,1 1� Op W i. 1TBM=62.00 Q b�� E { D r
O �, TOF=62.70 ���— ICOR CONC. PAD /, t 0 w OF
O o 1 W Mqs
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DA M.
EYER
WOODED SANGI AR
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— 1 N89.24'10"E 154.03' DARREN M. MEYER, R.S.
60
P122�o8s P.O. B 0 X 981
GRAPHIC SCALE - � EAST SANDWICH MA. 02537
20 0 10 20 40 80 PARCEL ID: } '
122/090 (508)362-2922
r
( IN FEET )
1 inch = 20 ft. SHEET 1 OF 2 J 1317
ELEV. TOP t «
FOUNDATION NOTE: MAGNETIC TAPE TO BE PLACED OVER ALL COVERS
(Existing) ` FINISHED GRADE (61.0)
'rr = 62.70 F.G.EL: 61.0 F.G.EL: 60.75 F.G. EL: 60.75
a ! MAINTAIN 2% MIN SLOPE OVER LEACHING AREA
9 PAW,
.� VENT
f ' 2" OF 3/8" DOUBLE WASHED
j 3/4" - 1-1/2"
i.:
j'. STONE OR FILTER FABRIC DOUBLE WASHED STONE
A
6 4" SCH 40 PVC
.4. 10"1 EErE3E
7
®®• O ®®®®
14' 6 ® S= 1 (MIN. ®®®®®®®®®TEE'S ARE TO BE INV.57.20 t ) ®®®®®®®®®4' SCH 40 PVC 2 EFF. DEPTH ®®®®®®®®®
INV.57.75 T
1 GAS INV.57.0 4' 2 X 8.5' 4'
PROPOSED J
DB-3
EXISTING OUTLET BAFFLE EFFECTIVE, LENGTH 25'•
EL59.63 " "" " ' H-10 DISTRIBUTION BOX
INV. 58.0 PROPOSED 1 ,500 GALLON SEPTIC TANK INV. ELEV.= 56.00
OF MAS
GAS BAFFLE TO BE INSTALLED ON �P� sq BREAKOUT
OUTLET TEE AS MANUFACTURED BY D � y ' ELEV.= 5 6.5
R
TUF-TITE, ZABEL, OR EQUAL TOP CONC. ELEV.= 56:50
o. 1140 "' INV. ELEV.= 56.00 �®®~ O ®®
NOTES: 1) CONTRACTOR SHALL VERIFY ALL EXISTING r' I®®®®®®®MW
.
PIPE INVERTS PRIOR TO CONSTRUCTION �P ®®®®®®®
F-StE � ®®®®®®®
2) TANK AND D-BOX SHALL BE SET LEVEL AND TRUE SNIT000 BOTTOM EL.- 54.00 ®®®®®®®
TO GRADE ON A MECHANICALL COMPACTED SIX 3.75' 5 FT. 3,75'
• INCH CRUSHED STONE BASE, AS SPECIFIED IN _ � dl = .5'
310 CMR 15.221(2) SEPARATION 5.10 FT. EFFECTIVE WIDTH, 12
3) INSTALL INLET & OUTLET TEES AS REQUIRED SEPTIC SYSTEM PROFILE
BOTTOM OF TESTHOLE EL: 48.9 - SOIL ABSORPTION SYSTEM ION
(500 GALLON LEACH CHAMBER -20) LOADING)
GENERAL NOTES: SOIL LOGS P#:13226 P
DESIGN CRITERIA
r NUMBER OF BEDROOMS: 3 BEDROOOM
1• ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL SOIL TEXTURAL CLASS: CLASS I (0.74 GPD/SF)
BOARD OF HEALTH AND THE DESIGN ENGINEER. DATE: MARCH 29, 2011
2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS DESIGN PERCOLATION RATE: <2 MIN/IN
OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE SOIL EVALUATOR: DARREN MEYER, R.S., CSE #1614
LOCAL RULES AND REGULATIONS, EXCEPT AS REQUESTED BELOW: ' DAILY FLOW: 110 G.P.D. X 3 -BR = DESIGN FLOW: 330 G.P.D.
1) A 1.50 FT. VARIANCE
FROM 310CMR15.221(7) TO ALLOW LEACHING TO BE
WITNESS: DAVID STANTON; B.O.H.
1) A isRI (B): GARBAGE GRINDER: NO (not designed for .garbage grinder) '
� -
4.50 FT (MAX) BELOW GRADE VS REQ'D 3 FT. (H20/VENT PROVIDED) p SEPTIC TANK: 330 gpd x 200% = 660 gpd USE PROP. 1,500 GALLON SEPTIC TANK
3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR Elev. TP- 1 Depth Elev. TP-2 Depth
TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE
DESIGN ENGINEER. 60.10 01. 59.90 0" LEACHING AREA REQUIRED: (330) = 445.94 S.F.
4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING A LOAMY OYR 4%2D i A LOAMY
4/2D 74
FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN 59.43 8" 59.32 7"
ENGINEER BEFORE CONSTRUCTION CONTINUES. B ## B USE TWO (2) 500 GALLON PRECAST LEACH CHAMBERS W/ 4' STONE
5. ALL ELEVATIONS BASED ON ASSUMED DATUM. SANDY LOAM i SANDY LOAM '
6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF 10YR 6/8 E 10YR 6/8 ON SIDES & 3.75 STONE ON SIDES: ,25 L x 1.2.5 W x 2 D
THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF BOTTOM AREA: 25 x 12.5= 312.5 SF
HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. t
7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. SIDE AREA: (25 + 12.5) X 2 X 2 = 150 SF
8.ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED 56;43 C 44" 56.15 C 45"
TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR. TOTAL SQUARE FEET PROVIDED = 462 vs. 445.94 REQ'D
9. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY THE MEDIUM SAND MEDIUM SAND DESIGN FLOW PROVIDED: 0.74(462 S.F.) = 342.25 G.P.D. vs. 330 G.P.D. req'd
THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING PERC O EL. 54.75
10. EXISTING TANK TO BE REMOVED AND PIT TO BE PUMPED, CRUSHED AND FILLED PER TITLE 5. 2.5Y 7/4 2.5Y 7/4 PROPOSED SEPTIC SYSTEM UPGRADE PLAN
11. 48 HOUR NOTICE FOR ENGINEER CERTIFICATION 49.10 132„ 48.90 132° 1 20 SETH GOODSPEED'S WAY, OSTERVILLE, MA
12. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY �
AND IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY PERC RATE <2 MIN/IN-("CI" HORIZON) Prepared for: Doherty
13. NO PRIVATE WELLS WITHIN 150' OF PROPOSED LEACHING. NO GROUNDWATER;OBSERVED
t Engineering
'by: Surveying by: SCALE DRAWN
14. NO WETLANDS WITHIN 150' OF PROPOSED LEACHING. • I, Darren M. Meyer. R.S., CSE, hereby certify that I am currently approved b MADEP DARRENM MEYER,R.S. AlecDo alJ Surve DMM
y y y y pursuant to 310 CMR 15.017 11B Y N.T.S.
15. ALL PIPING TO BE 4" SCH 40 0 1/8-/FT (UNLESS SPECIFIED) to conduct soil evaluations and that the above analysis has been performed by me consistent with the PO Box98f (508) 419-1086 DATE
16. LEACHING TO BE H2O LOADING, WITH VENT. requirements of 310 CMR 15.017. 1 further certify that I ha� passed the Soil Evol. Exam in October, 1999. EAST SANDWICH,MA0.2537 CHECKED SHEET N0.
508-362-2922 03 31 1 1 D M M
/ / 2 of 2