HomeMy WebLinkAbout0038 AGAWAM ROAD - Health 38 AGAWAM c-d
MARSTONS 1V��LLS
A = 043 007 020
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' TOWN OF BARNSTABLE
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LOCATION _33 ` J&U-01 � ) AG `
VILLAGE nkr S t o ��S ASSESS01;'S MAP 8f LO
INSTALLER'S NAME&PHONE NO. �A��G
SEPTIC TANK CAPACITY _/f" a2 CC
LEACHING FACILITY: (type) L L00L (size) /3 X z-7
NO.OF BEDROOMS `3
BUILDER OR OWNE r
PEWMITDATE: COMPLIANCE DATE:
- � I
Separation Distance Between 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
i
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3 Zs. IS
3Y6. �° .
J
Fee SO .
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
01pplitation for �Digaal *pgtem Conotruction Permit
Application fora Permit to Co struct( )Repair( )Upgrade( )Abandon( ) O Complete System 0 Individual Components
Location Address or Lot No w n VK Owner's Name,Addres!!^ Tel moo.
/Parcel
�?, M ':
Assessor's Ma —
p �D _ D c,1 a C5 LvT a x A y4 W A M
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
VOd S Kc nu A-� �hC
►�� If3�, 1 �G� vr�r+s6i �� v�,
Type of Building: +'
Dwelling No.of Bedrooms '1 Lot Size sq. ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow_`'_3 3 V gallons per day. Calculated daily flow gallons.
i
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) 7�u S 4 4 17 Q O ' C.� / 44
Date last inspected:
Agreeiment:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issue by this and Health.
Signed Date j 4Z 7/0 0
Application Approved by An .. ?t�l Date t 7
Application Disapproved for the following reasons
Permit No. ZD00 — LA Co Date Issued_ k L _E O
No. D Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
Application for Migonf *V,tem Construction vermit
Application for a Permit to Co truct( )Repair( )Upgrade( )Abandon( ) D Complete System ❑Individual Components ,
Location Address or Lot No.. LG 1��w(\VIA Owner's Name,Ad ress a^^TPl No.
Assessor's Map/Parcel � U U c'�. wT a), A VIA
Installer's Name,Address,and Tel.No.. Designer's Name,Address and Tel.No.
S EKcfvu 0, 1`4
1 0 >r3 vt, 116-1 /�►��s�i �� �� �l
Type of Building:
Dwelling No.of Bedrooms ? Lot Size sq. ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 33 U gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) �S `�/� 17 Q O ' cj I .7
00 A C6 /I J
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issue byythis and Health.
Signed Date /4Z 7/0 0
Application Approved by ,LQJ>_�w. Date !'I 7
Application Disapproved for the following reasons
Permit No. ZdC70 - (A t o Date Issued l t � 2� � Ob
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certif irate of (Compliance
THIS IS TO CERTIFY, that the On-site Sewa e Disposal System Constructed ( ) Repaired ( ) Upgraded ( )
Abandoned ( )by a'�1 r �Kc,a Uc� w�
at_M1133 a 5 A c-..:>it to has been constructed in accordance
with the pr visions of the 5 and the for Disposal System Construction Permit No. WW Lpge.P dated---,I I 1 J-- 1 O-D .
Installer yJ Designer —T-�
The issuance of this a 't s a of f`�strued as a guarantee that the s ste i]AMS An .
P t '✓ g Y
Date (-J Inspector � l
i
--•---- /—,i---------------------------------
No. Obb✓ w I� Fee ID
'
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Mwigoaf *v5tem Cold,5truction Vermit
Permission is hereby granted to Construct( )Repair(X Upgrade( )Abandon( )
System located at- 3$ A(,V\\tQ wM 9-b M l 1.1.0
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 must be completed within three years of the date of this permit.
Date:__I f r, Approved by ) ta� sdsc _ u
1/6/99
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS)
, hereby certify that the application for disposal works
construction permit signed by me dated 1� '� ( U y , concerning the
33
property located at $ -11�3 A W meets all of the
following criteria: Y 4��S
• This failed system is connected to a residential dwelling only. There are no commercial or business
uses associated with the dwelling.
• The sail is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch.
• There are no wetlands within 100 feet of the proposed septic system
• There are no private wells within 150 feet of the proposed septic system
• There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
• The bottom of the proposed leaching facility will not be located less than five feet above the maximum
adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when
applicable]
• If the S.A.S.will be located with 250 feet of any vegetated wetlands,the bottom of the proposed
leaching facility will not be located less than fourteen(14)feet above the maximum adjusted
groundwater table elevation,
Please complete the following:
A) Top of Ground Surface Elevation(using GIS information)
B) G.W. Elevation +the MAX. High G.W. Adjustment. _
DIFFERENCE BETWEEN A and B
SIGNED : DATE: UU
[Please Sketch proposed plan o system onTack]:
NOTICE
Based upon the above information, a repair permit will be issued for bedrooms maximum. No
additional bedrooms are authorized in the future without engineered septic system plans.
q:health folder:cert
TOWN OF BARNSTABLE
a Lrat a., AG �
LOCATION f„
I VILLAGE !'1�f SYo �S ASSESSOIeS MAPI•fJ LO
INSTALLER'S NAME&c PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) 0 C T(size) �� X Z
! NO.OF BEDROOMS 13
BUILDER OR OWNS J
PEF.MITDATE: �CON�2LLIkN�CEDA�' I ��
f
Separation Distance Between 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
a
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o ti�
ra
COMMONWEALTH OF MASACHUSETTStit
EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET BOSTON MA 02108(617)292-3500
TRUDY COXE
Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 38 AGAWAN RD MARSTONS MILLS, MA 02648 M043 P007 L020
Name of Owner PAUL GAGE
Address of Owner: 38 AGAWAN RD MARSTONS MILLS,MA 02648
Date of Inspection: 10/2/00
Name of Inspector: JOHN GRACI
1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)
Company Name: SEPTIC INSPECTIONS
Mailing Address: P.O.BOX 2119 TEATICKET,MA.02636
Telephone Number: 608-564-6813 FAX 508-564-7270
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 Evaluati By the Local Approving Authority
X Fails
Inspector's Signature: "( Date: 10/3/00
The System Inspector shall su mit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of
J,f
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
"The inspection is based on criteria defined in Title V code 310 CMR 15.303.My findings are of how the system is performing at the time of inspection.M,.
inspection does not imply any warranty or guarantee of the longevity of the septic system and any of its component's useful life."
THE SYSTEM FAILS TITLE V INSPECTIOW.THE LEACH PIT WAS FULL OVER THE PIPE,THE PIT HAD NO EFFECTIVE LEACHING LEFT AT THE'
TIME OF THE INSPECTION.THE PIT HAD SOLID CARRYOVER.
revised 9/2/98 Paae 1 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 38 AGAWAN RD MARSTONS MILLS, MA 02648 M043 P007 L020
Name of Owner PAUL GAGE
Date of Inspection: 1012/00
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
r.
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.
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 o
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.
n/a 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.
nta Sewage backup or li�eakout or high static water level observed in the distribution box is due to broken or obstructedpipe(s)o,
9 P 9
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
nla 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
t4
III
revised 9/2/98 Paoe 2 of 11
"SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 38 AGAWAN RD MARSTONS MILLS, MA 02648 M043 P007 L020
Name of Owner PAUL GAGE
Date of Inspection: 10/2/00
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 I:
NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of 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 I 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 n1a (approximation not valid).
3) OTHER
n/a
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!
4
revised 9/2/98 " Pape 3 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 38 AGAWAN RD MARSTONS MILLS, MA 02648 M043 P007 L020
Name of Owner PAUL GAGE
Date of Inspection: 10/2/00
D. SYSTEM FAILS:
You must indicate either"Yes"or"No"to each of the following:
X 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
X _ Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool.
_ X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow,
_ X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped n/a.
X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
_ X Any portion of a cesspool or privy is within a Zone I of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well,
_ X Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water
quality analysis. 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"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
X the system is within 400 feet of a surface drinking water supply
_ X the system is within 200 feet of a tributary to a surface drinking water supply
X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone 11 of a public water supply
well)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412). Please consult the local regional office of
the Department for further information.
revised 9/2/98 Paoe 4 of 11
a
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 38 AGAWAN RD MARSTONS MILLS, MA 02648 M043 P007 L020
Name of Owner: PAUL GAGE
Date of Inspection: 10/2/00
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
Yes No
X _ Pumping information was provided by the owner,occupant,or Board of Health.
X 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.
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,excluding 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,For example, Plan at B4O,H,
X _ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)1 5.302(3)(b)]
X _ The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal
Systems.
revised 9/2/98 Paae 5 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 38 AGAWAN RD MARSTONS MILLS, MA 02648 M043 P007 L020
Name of Owner PAUL GAGE
Date of Inspection: 10/2/00
FLOW CONDITIONS
RESI— DENTIAL:
Design flow: 110 g.p.d./bedroom
Number of bedrooms(design): 3 Number of bedrooms(actual): n/a
Total DESIGN flow: 330 gpd
Number of current residents:6
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): n/a gpd
Sump Pump(yes or no): NO
Last date of occupancy: n/a
COMMERCIALL/IND (STRIA
Type of establishment: n/a
Design flow: n/a gpd(Based on 15.203)
Basis of design flow: n/a
Grease trap present:(yes or no): NO
Industrial Waste Holding Tank present:(yes or no): NO
Non-sanitary waste discharged to the Title 5 system:(yes or no): NO
Water meter readings. if available: n/a
Last date of occupancy:n/a
OTHER: (Describe)
n/a
GENERAL INFORMATION
PUMPING RECORDS and source of information:
n/a
System pumped as part of inspection:(yes or no):NO
If yes,volume pumped n/a gallons
Reason for pumping:n/a r!f
TYPE OF SYSTEM
X 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: n/a
APPROXIMATE AGE of all components,date installed(if known)and source of information:
1987-PERMIT 87-528
Sewage odors detected when arriving at the site:(yes or nq.) No
S�Y
revised 9/2/98 Paoe 6 of 11
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 38 AGAWAN RD MARSTONS MILLS, MA 02648 M043 P007 L020
Name of Owner PAUL GAGE
Date of Inspection: 10/2/00
BUILDING SEWER:X
(Locate on site plan)
Depth below grade: 30"
Material of construction: _ cast iron X 40 Pvc _ other(explain)
Distance from private water supply well or suction line: n/a
Diameter: n/a
Comments: (condition of joints,venting,evidence of leakage,etc.)
TOWN WATER
SEPTIC TANK: X
(locate on site plan)
Depth below grade: 24"
Material of construction: X concrete_ metal_ Fiberglass_ Polyethylene_ other
explain: n/a
If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NO
Age: n/a
Dimensions: 1000G L 8'6"H 5'7"W 4'10""
Sludge depth: 3"
Distance from top of sludge to bottom'of�putlet tee or baffle: 31"
Scum thickness: 2"
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: n/a
How dimensions were determined: MEASURED
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 SEPTIC TANK IS STRUCTURALLY SOUND.THE SYSTEM FAILS,THE LEACH PIT IS PAST THE EFFECTIVE DEPTH OF LEACHING.PROPEI
MAINTENANCE FOR SEPTIC SYSTEM IS TORUMP EVERY TWO YEARS.
GREASE TRAP: _
(locate on site plan)
Depth below grade: n/a
Material of construction: _concrete_ metal_ Fiberglass _ Polyethylene_other
Explain: n/a
Dimensions:n/a
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle n/a
Date of last pumping: n/a
Comments:
(recommendation for pumping,conditioncof inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of
leakage,etc.)
nla :I
re
vised 9/2/98
Paoe 7 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 38 AGAWAN RD MARSTONS MILLS, MA 02648 M043 P007 L020
Name of Owner PAUL GAGE
Date of Inspection: 10/2/00
TIGHT OR HOLDING TANK: _ (Tank must be pumped prior to,or at time of,inspection)
(locate on site plan)
Depth below grade: n/a
Material of construction: _concrete_ metal_Fiberglass _Polyethylene _other
Explain: n/a
Dimensions: n/a
Capacity: n/a gallons
Design flow: n/a gallons/day
Alarm present: NO
Alarm level:N/A Alarm in working order: NO
Date of previous pumping: n/a
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
n/a
DISTRIBUTION BOX:X
(locate on site plan)
Depth of liquid level above outlet invert: n/a
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.)
DID NOT EXPOSE
PUMP CHAMBER: _
(locate on site plan)
Pumps in working order:(Yes or No): NO
Alarms in working order(Yes or No): NO
Comments:
(note condition of pump chamber,condition of pumps and appurtenances.etc.)
n/a
revised 9/2/98 Pape 8 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 38 AGAWAN RD MARSTONS MILLS, MA 02648 M043 P007 L020
Name of Owner PAUL GAGE
Date of Inspection: 10/2100
SOIL ABSORPTION SYSTEM(SAS): X
(locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods)
If not located,explain:
n/a
Type:
leaching pits, number:(1)1000 GAL 6'X 6'
leaching chambers,number: (n/a)n/a
leaching galleries,number: (n/a)n/a
leaching trenches,number,length: (n/a)n/a
leaching fields,number,dimensions: (n/a)n/a
overflow cesspool,number: (n/a)n/a
Alternative system: n/a
Name of Technology: n/a
Comments:
(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.)
THE SYSTEM FAILS TITLE V INSPECTION.THE LEACH PIT IS FULL OVER THE PIPES,THE PIT HAS NO EFFECTIVE LEACHING LEFT.THE PIT
HAD SOLID CARRYOVER. '{
CESSPOOLS: _
o Vv f
(locate on site plan)
Number and configuration: n/a
Depth-top of liquid to inlet invert: n/a
Depth of solids layer: n/a
Depth of scum layer, n/a
Dimensions of cesspool: n/a
Materials of construction: n/a
Indication of groundwater: n/a inflow(cesspool must be pumped as part of inspection)NO
Comments:
(note condition of soil,signs of hydraulic failure,•level of ponding,condition of vegetation,etc.)
n/a
PRIVY:
(locate on site plan)
Materials of construction: n/a Dimensions: n/a
Depth of solids: n/a
Comments:
(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.)
n/a
W
revised 9/2/98 Paae 9 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 38 AGAWAN RD MARSTONS MILLS, MA 02648 M043 P007 L020
Name of Owner PAUL GAGE
Date of Inspection: 10/2/00
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)
a �
AR
Q &5 31
revised 9/2/98 Paae 10 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 38 AGAWAN RD MARSTONS MILLS, MA 02648 M043 P007 L020
Name of Owner PAUL GAGE
Date of Inspection: 10/2/00
NRCS Report name: n/a
Soil Type: n/a
Typical depth to groundwater: n/a
USGS Date website visited: n/a
Observation Wells checked: NO
Groundwater depth: Shallow_ Moderate_ Deep_
SITE EXAM _ Slope
_ Surface water
_ Check Cellar
_ Shallow wells
Estimated Depth to Groundwater 12 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
Checked local excavators, installers
X Used USGS Data
Describe how you established the High Groundwater Elevation.(Must be completed)
USGS MAPS AND CHARTS-12+FEET
II
revised 9/2/98 Paqe 11 of 11
fts6i N f BARNSTABLE
LOCATJ.ONJQT SEWAGE #
VILLAGEASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO. Y,
SEPTIC TANK CAPACITY-1 S 0
LEACHING FACILI Y:(type)
NO. OF BEDROOM PRIVATE WELL OR BLIC WATE -
BUILDER OR OWNER M c-Y,2 Or G ,;�-®U (�
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED: 5- - 13 -8 a
VARIANCE GRANTED: Yes No t-'
` �� � �
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r 6 U
`303 �� 3 �
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,j TOWN OF BARNSTABLE
LOCATION %A , -m \D ,SEWAGE # - 5-2Ir
VILLAGE t�,o,cs�ohS m���S ASSESSOR'S MAP & LOT y
VNSTALLER'S NAME & PHONE NO.
EPTIC TANK CAPACITY Q Q
�1 EACHING FACILITY:(type) (size) GO O
NO. OF BEDROOMS PRIVATE WELL OR UBLIC WAT
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No �/
21
�l
act
No... .�
THE COMMONWEALTH OF MASSACHUSETTS
�- BOARD F TH
....................OF.... .........:... :... ....................................
Appliration for Disposal Works nnstrnrtiun rrrntit
Application is hereby made for a Permit to onstruct ( or Repair ( ) an Individual Sewage Disposal
System . ..
- ca on-Address r Lot No.
.... . �.. _ _.... . .............................._... ........................-�--.-�._e g
dres------------------------------------------
i - Address. . 1.................................. •---......------............•............... ---........................................
Inst er Address J/�'
Type of Building Size Lotl._fi#..,��? ..Sq. feet
Dwelling—No. of Bedrooms..... Expansion Attic ( ) Garbage Grinder (
WOther—Type of Building ............. ........... No. of persons.................._......... Showers ( ) — Cafeteria ( )
Otherfixtuges...---------•--.....--•------....-•--••-•--••-•-•--.....-•------------------•--------------•......--.....---...--------------------------------------
Design Flow ...._... gallons per persor3,peay. Total dailY "w.-----.i �- .. _
WSeptic Tank—Liquid'ca.pacit� .gallons Length.`0e:_ ...... Width.% ..... Diameter................ Depth- _.-_..,
Disposal Trench—No. ... �'._. Width. ............... Total Length..---.---_ -----_ Total leaching area........... sq. ft.
See e Pit No...�Q/��_..._ iameter._..1 ........ Depth below inlet---3�.5:......_. Total leaching area .-0T ._ ft.
Pa P g sq
Z Other Distribution box ( Dosing-1
Percolation Test Results /Performed by .:..a�rr� � 1......:........ .:................ Date.. _._.__....-.
a 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........................
a -•--•-• ------------------------------------------------------------------------------------------------•------•-•--•--....---••-•--•••......-•------•--
0 Description of Soil........................................................................................................................................................................
W
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 TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place t system in
operation until a Certificate of Compliance ha be sued by e bo d of healt
Signe ..dam efG� r/U L f.�... ...........
Date
Application Approved By................ Vic- ._....................... ---------
Date
Application Disapproved for the f n r ons:---•-•...........................•-------------------------•-••••-•--•-•-•-----................................
.....................•-•---•-•--•-----•---•---•-•--•-•-•----•-------•---------••---.........--------.........----.........--------•---•-----••----....-•--------------------•-.....••--------------------
Date
PermitNo...... .2 .7-------------------_ Issued--------•-----............-•------------------•-----..
Date
I.+
�1 1
No.2.2 S9- . FEs.. r._.=
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...----........"."".....................-OF..........................................................................................
Appliration for Disposal Works Tontrudion ranfit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
................__......_...................................................................... _......--••-•---.......---........--•--•-"-•-•-•-----._..•----"'.._.............................
Location-Address or Lot No.
...............................................
Owner•r ttAt'd�dress
W
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 ( )
QI Other fixtures -------------------------------- .
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid'capacity............gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area...................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation 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........................
p+' .........................----•---•--•.................----•-.....-----.......--•••••--•-'••'-'---......._••-•--•--------••-----...........---•-•------..--•-
ODescription 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 TIT LE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed......................•----•-----------•----..............---•-•.........------...._.. ..........................
Date
Application Approved By.................. --••••---.--... ------ ............-----•...--.------•--------•------•--------•--•---- e — lilate e "1
Application Disapproved for the f of ing r ons:--•-----•--•------------------------------------------------------------------........ �• _._.
--------------•-----------•-------•------•---------------------•----------••-----.................-------.-------•••-•-••-•---------------------------------------------------_.... ......-------••-
Date
Permit No..- =- �•----•-------••--_..... Issued.•...•-•...............
/ / Date... ...............
COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF.....................................................................................
QW.IrrfifiraU of Tomplinnrie
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by.....................................................................................................................................................................................................
Installer
at------------------------------------•----------------.------•-•-------------------•---------------------------------------------------------------------------•--•----------------------------------
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit N ---- ------------------------ dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL -- E'3ONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE....................... •-•--•-••'-•--•-•-•-••------ Inspector....................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
N ��... .. ....... ............OF. ---------------------------------------- FE ..
deposal Yorks Tlans#rnr#ion anti#
Permission is hereby granted-- --------------- .... ----------.----•--------------------.-.-.--------------------------•---••--.-.---
to Construe ) or Repair ( ) an vidu e-a ag�kstem
at No............... .. ..................
. -
------------•--------•------•--------•---------------
as shown on the application for Dis osal Works Construction Permit No..................... Date --------
-----.-.-.--.............
DATE.............. ................................. ------------------------------------------
Board of Health
f-�- -�...----•--.._..
FORM 1255 A. M. SULKIN,INC., BOSTON
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SCALE : , l/PPERCAPE E1V61NEER/.VC .ree NO. 6z v
/ = YO P.a. ASS-Oa -
DAT,E•• SHEET of Z
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TOP OF FOUNDATION. i
COVER
CONCRETE. COVERS
e 4"CAST IROrJ 2 �mr •;TT�,T ►nm, '.
. To X0
OR SCHEDULE 4t� ,. 1�"MAX. '
i .• ' 'P.V.C. PIPE ' 4 •SCHEDULE 40 PV.C.(ONLY�
PITCH. I/40PER.F4 PIPE - MIN:. LEACH
PITCH 1/4"PER.FT. PIT
INV RT �. / ' PRECAS
,.e EL:Y sro Q. LEACNII.
° SEPTIC. TANK INVERT DIST.. INVERT : . �. Q.: PIT OR
e INVERT EL.?T. ELB X,Z EOUIV
'a EL.$.�XS.. .� :, GAL:. INVERT 90X �
; I ELVA— INVERT ni ww ` 3/4"TO II
EL.�$.K� w0�: WASHEI
/0 STONE
�.,
iA
PROFILE OF _ — —
A/j GROUND WATER TABLE
SEWAGE DISPOSAL : SYSTEM
} NO SCALE
- 33 .
• - P
S I L LOG WITNESSED BY
DATE .21.2 ��.... TIME.. ... .. ....
TyQ7. •h•/��0 BOARD OF. HEALTH
TEST HOLE I TEST HOLE 2 S_ Ti'!•�Or3 i
ELEV. .. ENGINEER .
.�x�/p
p- T
DESIGN DATA
NUMBER OF BEDROOMS ,
TOTAL ESTIMATED FLOW '3 a • , ,-GALLONS/BAY. .
BOTTOM LEACHING .AREA '` p F
.. . � : S0.FT. /PIT .
SIDE LEACHING AREA . .:. 10.y', . .: : SO.FT./PIT
GARBAGE DISPOSAL �y(50% AREA INCREASES '
- TOTAL LEACHING AREA D,�7, SO.FT
80• i PERCOLATION RATE .4,,$ S Z. MIN/INCH
'�..WATER ENCOUNTERED
i LEACHING AREA PER PERCOLATION RATE .r='. SO.FT.
I NUMDER OF LEAC ING .PITS AvG- ,
2. �`
-
APPROVED , , , , , , BOARD OF HEALT�I .Z'flQ .- 3,�y �,� •_ �� Jl . 7? . P0
DATE �.,�Ss'�� 6, � i p s ._7
� . . ,
' AGENT OR:INSPECTORJ f D7W
yy�p%AL Sqy/
,(oT.
y. . . . . . . . . . . . .i. /iATEQ.A� �o,Q /V Fr /N
4NO TD �.v ACOB� �
.�I ri�EQ.�/ .�U.•�To n. �-3� �.0' o,c' o� td0.81
.PETITIONER
„:r y 'r• t,•
No...
- - THEBO/"�RD COMMONWEALTH FUASS;CHU u S
f C-1 �1 I-1
f?....................OF..... .:........... .... ...._ ............................................
Appliratiun for Disposal Works nstrudion VCrrmit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individdual Sewage Disposal
System
.... .�c.t.�,t?. ,... .. .................. ..... ............------:...........----------------......
on-Address or Lot No.
•...... ...... — - -
Ow Address
a .. a..l... . .l .................................... ............................................................•----.................................
taller .`Address
Type of Building :Size Lot.O7.l3 7f:::..Sq. feet
U Dwelling—No. of Bedrooms --- ------------------------------Expansion Attic ( ) Garbage Grinder Vp�
Other—Type T e of Building ._........ No. of persons............................ Showers — Cafeteria
a YP g •--- •---•--� P ( ) ( )
W Other_ jix s ••-- -•------•-----•---
"..55 -.._................................. ...•--•-----•--• -............. -------
..----------
w Design Flow.............. ............................gallons per person,-,PPe9r day. Total daily•flow.._....33.42..:-.................... Ions.
WSeptic Tank—Liquid'capacityll/ '1.1.gallons Lengths'I�_,7 ..... Width.r,� __ Diameter................ Depth., ......._.
x Disposal Trench—No...................... Width....................Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..40V ..__. iameter..../10......... Depth below inlet1r-,fl.. Total leaching area ._ q..sft.
z Other Distribution box ( Dosin�.� ) r
~' Percolation Test Results _,,Performed by. V ��. i...........:............................ Date.._ /�
,aa Test Pit No. 1.......Y-.minutes per inch Depth of Test Pit..1- .__. Depth to ground water...!-If'..�.............
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a ...---•---•........................................•---••---•--......--------•------......__......-----...
-...
.-...-------
-..----------------------------
----
0 Description of Soil........................................................................................................................................................................
x
c,
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 ha b issued b e boprd of heap.
Z/
Signed._. ------.... ` .�`//�94).... . ....
Date
'Application Approved By----•--•----. . l.. __.._. ....
” — 7
Date
Application Disapproved for the following reasons:-•----•-----•---......--••----•--•------••-------------•-------......---......------•-----------•--------------
.............................•-•-•----.....--•--......--•------................---•-----.........--------••----•--------•----•---•--.---•-•---•---••---..........................-- . -•-...--------
Date
Permit No.......S.:>-=-..5.-g..!.....-•--....... Issued..........................•--------....................
Date
No2._7_.......5a:.? Fx$..7...
THE COMMONWEALTH OF MASSACHUSETTS
l
BOARDS QF H A H
.................t ----------------OF........!�. ..�..I 2'..... -.........,...............................................
Appliratiou for Disposal a"or
tts�iutt Prrutit
Application is hereby made for a Permit to Construct ( air ( ) an Individual Sewage Disposal
System
.... .. . ...
�• oca€ion- 10/s,,_,41 7 7/
Address � or Lot No.
............................................................... . . ...................
a UM �7 .... .-all ..... ...............Address............ ......_..
Installer Address ��1� ��
Q Type of Building Size Lot...__._`...:................Sq. feet
U Dwelling—No. of Bedrooms n....:._..................................Expansion Attic ( ) Garbage Grinder (44)pa, Other—Type of Building _.._�' ................. No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fix res ..---•-•--------•--------•-
Design Flow............................................gallons per person per day. Total daily flow......=_1_}_3_�-�.__....__._..............gallons.
WSeptic Tank—Liquid'capacity!�? •gallons Length�...�K..... Width.�Z%. ... Diameter................ Depth.`/......._.
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No.?111A...._..,Diameter....q......... Depth below inlet- _�L�_..... Total leaching area.w-___...sq. ft.
z Other Distribution box (V/)" Dosing tank(j ) �f
~' Percolation Test Results Performed by.."-�.... .............:� ......................................... Date...7. !.._.e`.'~_.--........
Test Pit No. 1....... 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........................................................................................................................................................................
W
V ....---•••••---•••••---••-•••-••-----•----•-•------•-------••••....••---••--...--••-••-•---•--•••...........................................•---•-•-----••----•-------•••------•--•----•-•-•--..._-•----
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 y the board of health. �Signed /i ...........................•-•----------•-..................------.._ ?..... Dat —
Ir
Application Approved By............•••••...- � L-' `"`-- •--------F� ....... -1--
Date
Application Disapproved for the following reasons:............................................................................................................
........-•..................••---•--..........--•-----------...-----------•-----•---------•-•-------••--•..-----.............----------------•-----•------------•---------------...--•••••-••------_...._
Date
Permit No...... ,,. ..::._: _.�Z `� ....... Issued.............................
---•-------- --•----------------•-------
Date
THE COMMONWEALTH OF MASSACHUSETTS
_ BOARD OF HEALT
�. —
.. .. ........................OF...,y.... ��.....�:....,,. ,.........................................
(Irrtifirtttr of Toutpliana
W S � T0�ER fFY, T _ Individual Sewage isposal System constructed (✓ or Repaired ( )
Y--- -- -•--I -- =
at.... ..
has been installed in accordane:r ith the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works,,Construction Permit No $.7. ....._......�........ dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. _
�—,
DATE.....................,a�... .t.-. ..�:-UO................................ Inspector................ ...............................................
-- ---
THE COMMONWEALTH OF MASSACHUSETTS
�-_ BOARD F 1ALTu
OF 1
No.. .7_. FEE........................
Permission is hereby granted�__! 1.... ! ` -.. �l_.
...............................................................
to Construct- )�r Repair ( /) an Individual Sew ge D iposal System
•• ---
$treet 1 52
as shown on the application for Disposal posal Works Construction Permi o-------------------- Dated.. _.-____-__-----_------.....__........
..-----•.------ Q -----•..... .
.....
...•.... Board of Health
DATE ------------------------
FORM 1255 A. M. SULKIN, INC., BOSTON
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OR SCHEDULE 4d2 MAX,
• � Nam. -�� Fin/
P.V.C. PIPE ' 4 ' CHEDULE 40 PV.C.(ONLY) I�•MAX. '."'T"�' .
?a of PITCH 1/4"PER,FT PIPE•- MIN
PITCH 1/4-PER,FT LEACH
PIT
o' �INVE T PRECAS
'•� EL.g J
"'• Xo SEPTIC TANK , INVERT IN ERT : . Q.; PITCOR
.•e INVERT. ELlZOV DIST. EL 7XO w
GAL: 'INV FFA�T Box 1 >X � t; EOUIv
EL !Xy INVERT �a
ni w w �: :.�: 3/4"TO 1 I
e I EL CA2.. :i u- WASHEI
42NE
••� /0 ' DIA,
- PROFILE . OF Ni GROUND WATER TABLE
SEWAGE.. DISPOSAL - SYSTEM t`
P NO SCALE
X
LLOG. WITNESSED BY :
DATE .71.F6 .... TIME.. ... .. ...:
T110.1 •;eeo 41 BOARD OF HEALTH
TEST HOLE 1 . TEST HOLE 2 S- Ti'rCOr3 i
ELEV, . ENGINEER
// DESIGN DATA :
NUMBER OF BEDROOMS
i
TOTAL ESTIMATED FLOW3�, ,.GALLONS/DAY
BOTTOM LEACHIIG AREA ?p, : SO.FT. /PIT
SIDE LEACHING AREA . ... lo.j� SO.FT./PIT
GARBAGE DISPOSAL . . !✓Q. ..(50% AREA INCREASE)
TOTAL LEACHING AREA � 7, , SO.FT
PERCOLATION RATE .�,�; S, 2. MIN/INCH
LEACHING AREA PER PERCOLATION RATE .. . . ... SO.FT.
......WATER ENCOUNTERED -
NUMBER OF LEl1C ING PITS
APPROVED . .. . . . . • BOARD OF HEALTH R 2• '3'�y�rlS �i� r.) -
- 7.P. 6PD
DATE ! a, 2'�'/• =,L..�S(�� �� � i p.y s?-.S, �2 f
4Z>
! AGENT OR.INSPECTOR1
11
• 71` �/oTF: •�F �ootic�9B.lE/. NAI.
co
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•f�Glf�t/�f/7 . n �N
a. . . . VheecTiaa/s. �1 AIP TO No. 4
lT;ri EQ.r/ ,C44To r'. ,a-e v• ��,o WEALlPETITIONER �9�� �i DE Sell S/D F�P
-