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HomeMy WebLinkAbout0088 BLACKTHORN ROAD - Health 88 Blackthorn Road - ----- - ------- Marstons Mills A= 046-069 �\ '\ Commonwealth of Massachusetts Title 5 Official Inspection Form 6 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address 14✓'t, I-e w S6A kl'-G 4 t cl Ow ner ON ner's h}a"C., / �J 0o� / W �v f!/ information is rg- ID✓1 S � / b required for everyState Zip Code Date of In,pec ion page. City mown Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. important:When A. General Information filling out forms LN (J� bU on the computer, I use only the tab 1. Inspector: key to move your111),?vr4­, O e / cursor-do not f use the return Name of Inspector key. I/ ��/, f 0 Company Name 20 Company Address / /� if O� / raven �G,S ��i G✓`�I / / /`7 10 aL CitylTown �, _ /�� State Zip Code j �D Telephone Nu r License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: Passes ❑ Conditionally Passes ❑ Fails ❑ Needs urther Evaluation by the Local Approving Authority Inspector' Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)witnin 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 god or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform In the future under the same or different conditions of use. T i tl e 5 of f c,al lns pec tion l`orm,Su beurlace Sewage Disposal System-Page 1 of 17 t5ins•3/13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address ON ner Cw ner's Name � information is required for every �rS 4 0'15 / `'/��f/l �� aj page. City/Town State Zip Code Date of sp tion B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always com plete all of Section D A) Syste Passes 7I have not found any information which indicates that any of the failure criteria described in 310 CMR 15,303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ 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. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old' or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existirg tank is replaced with a complying septic tank as approved by the Board of Healt h. A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins,M3 Title50tficialIr%spe ficnForm.sumeacesewageoisposal system-Page2ofW Commonwealth of Massachusetts : _ Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form !-Not for Voluntary Assessments w — r � A,'G�✓7�f Or r 1 Property Address SLA/a lO/ 1 19 vl Owner ON ner's Namo S /� information is curs ✓► /'/� required for every page. City/Town State Zip Code Date of In ec' n B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(w,th approval of Board of Health): ❑ broken pipets) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ NO (Explain below): ❑ distribution oox is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ NO (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a mannerwhich will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh Ti11e501ficial trupecticnFUM Subsijrface Sewage Disposal System Pape 30117 5ns-3113 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address ' S M Ct IG ✓I On ner Ow ner's Name / 41 /J, /� information is / '"(�. ,s 41 / ,/�G O ,7 1 required for every page. City Frown State Zip Code Date of In ecf n B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environ;nent: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply, ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes f the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections! Yes No ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ �� Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ 1atic 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 l5ins•3/1 3 Title 5Official arts peclion F orrn Subsurface Sewage Disposal System•Page 4 oil Commonwealth of Massachusetts Mµ- Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form Not for Voluntary Assessments p' 9/61G/,- 76 0. IeCJ Property Address (A✓r, bla ✓1 Owner Owner's Name S T /�f ./� 21� �} l �23 /information is / l/ VO'- � required for every a page. City/Town State Zip Code Date of In pec on B. Certification (cont.) Yes No ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: . ❑ �, A-ly portion of the SAS, cesspool or privy is below high ground water elevation. ❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or trbutary to a surface water supply. ❑ [�'/ Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ Ly' Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ L� Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes If the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000g pd. ❑ The system fails I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone 11 of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. ism•2113 Title 5 Official ins peclionForm subsurface Sewaoe Disposal System—Page 5of 17 Commonwealth of Massachusetts Title 5 Officinal Inspection Form _ fi Subsurface Sewage Disposal System Form - Not for Voluntary Assessments , 1 Property Address S�/1�A b ( �'i ✓� ON ner ON ner.s Name r' Information is required for every _ Aak"r/�,,Jr page. Cityffown State Zip Code Date of In echon C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ �re any of the system components pumped out in the previous two weeks? ❑ the system received normal flows in the previous two week period? ❑ Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined? (If they were not a\ailable note as N/A) Was the facility or dwelling inspected for signs of sewage back up? ❑ Was the site inspected for signs of break out? Were all system components, excluding the SAS, located on site? ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Existing information. For example, a plan at the Board of Health. Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: 2 Number of bedrooms (design): Number of bedrooms (actual): 3_7D DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): t5ns•3113 Title 5 Of ficial Ins pec tion F orin Subsurf ace sewage Disposal Systom•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments o rye l2� Property Address urG� r V-3 ner On ner's Name inf //j// information is Grs ref / /( ff G,) required for every page. City/Town State Zip Code Date of Ingtectiofi D. System Information Description: / //O� SP 7-- N D Number of current residents: Does residence have a garbage grinder? ❑ Yes lam'rvo Is laundry on a separate sewage system? (Include laundry system inspection [] Yes No information in this repo-t.) Laundry system inspected? ❑ Yes 2 No Seasonal use? ❑ Yes No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑AY/es No /v Last date of occupancy: pa Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 GM R 15.203): Gallons per day(gpd) Basis of design flow :seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ns-3r13 Tide 5 Official Inspection Form.Subsulace Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address / ON ner Cw ner's Name information is rj�c�+f �/� required for every (/ page. City frown State Zip Code Nte of Ins action D. System Information (cont.) Last date of occupancy/use: Date Other (describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes 1?4--No If yes, volume pumped: gallons Howwas quantity pumped determined? Reason for pumping: Type of Sy m: Sep-ic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t&ns-3113 Title 5 0f ficia Im pec Lion F am:Subsurtace Sewage Dlsposel System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form v Subsurface Sewage Disposal System Form /Not for voluntary Assessments Property Address ON ner Ow ner's Name G) information is rs O required for every page. Gtyffown State Zip Code Date of Inspect' n D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 0 Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer (locate on site plan): Depth below grade: feet Matedal of constructi;��4O El cast iron PVC ❑ other (explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: feet (� Material onstruction: concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate ❑ Yes ❑ No Dimensions: Sludge depth: —� t5ins•M 3 Title 5 0f ficial Ire pec Ucn F orm Su bsurf ace$ewage Disposal System•Page got 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal �po System Form - Not for Voluntary Assessments p U �jGiGN' O✓h / Property Address StA ow ner CW ner's Name /,� information is ArJ J'V s l(.S /'/d �G /O - / required for every //// ��/� page. City rTown State Zip Code Date of Vspeeltion D. System Information (cont.) Septic Tank (cont.) Distance from top of s udge to bottom of outlet tee or baffle 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 �o How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): i/'1 f h rJT !// i G v1 41 G I/+� f /lam O b CC 4 G/�lQ /V� 1-e G �� Grease Trap (locate on site plan): Depth below grade: feet 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: pate ISIre•3/13 ilne5Offlciaf IrlspertionForm:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a I Subsurface Sewage Disposal System Form - Not for Voluntary Ass6sssssments Property Address QN ner Ow ner's Name �> information is vd ors S /lf 6 V7 /0 3 /tf required for every ._ page. Oityfrown State Zip Code Date of I spe tion D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pum ping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No l5ins•3/13 Title 5Dlfi0ial Inspecbon form.Subsvf me So wage Disposal System•Pago 11 of 17 Commonwealth of Massachusetts = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address (it ►��` bl A ✓1 ON ner Ow ner's Name information is AWS Vo�b 3 11114) required for every page. City/Town State Zip Code Date of Inspec ion D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): S0 �lf A/V Pump Chamber(locate on site plan): Pumps in worming order: ❑ Yes ❑ No' Alarms in working order: ❑ Yes ❑ No" Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): " If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ns,3113 Title 5Of Wal Ins pection Form Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 00�1c) �/e;c,4, 74�o/1t Property Address U�ah/a✓f Ovv ner Cw ner's NamA4rf�vli-f information isrequired for every page. City/Town State Zip Code Date of In pec ion D. System Informati ,n (cont.) Type; /' I ✓ l`�'7� leaching pits , number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leachl-ig trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/altemative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): /v V%1 o ✓rn a� //, 7' 11V �f�) /If e-I— d1h Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t51ru•Y13 Title 501ticialirspectio :orm:SubsirfaceSewageDisposalSystem•Page13o117 Commonwealth of Massachusetts - l Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary� Assse�-ssments0/✓1 /�O/ Property Address / --- Ow ner JC �/f G• I a infor Av ner's Name /h�']� equiredifor ievery G/57��J '�lS / //� 1J(/ t; A6 page. CitylTown State Zip Code Date of sp ction D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site Man): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3113 Title 5Offcial Iris poclicxiForm Subslrface SewageDlsposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System form - Not for Voluntary Assessmenta 9�p 40/0 Property Address Ow ner Cw ner's Name information is [ required for every Gig *A `r v �hsp?ctio�' page. Oty/Town State Zip Code Date D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two ermanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where lic water supply enters the building. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately d ` r) i ANl AA - 3c� 013 ,�73 - 50 6rns•3113 TiVe5Of66al Inspectia)Fam:Subsurf ace Sewage Disposal System-Page 16of 17 Commonwealth of Massachusetts -- Title 5 Official Inspection Form Subsurface Sewage 'DisposaI System Form - Not for Voluntary Assessments Property Address /_ ��� KJf�1 � Ov ner Cw ner's Name requiredfo is Gf/S oa s All �� l d required for every � / � dpC 6 �� l 3// !� page. City(Tbwn State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtainec from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health - explain: P/011 t 7&7-7 /76/ems ❑ Checkec with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must descri e how you established the high ground water elevation: c,,� �. - 1,4 •S S %moo �-_ �� Before filing this Inspection Report, please see Report Completeness Checklist on next page. 15ins•3/13 TWO 50feclai inspection Form Subsurface Sewage Disposal Sy8IOM-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �� 0/''1 Property Address ✓I avner ON ner's Name information is Xi required for every page. CAyllown State Zip Code Date of Inspect n E. �R,,epoort Completeness Checklist Lf Inspection Summary: A, 6, C, D, or E checked /l.,�,' inspection Summary D(System Failure CHteda Applicable to All Systems) completed I� 5ys m Information — Estimated depth to high groundwater L�1 Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•W3 TItte50fficidInspoc6onForm Subsurface Sewage Disposal System page 17of 17 OA> d , 4 6 6 q LOCATION L©T 33� SEWAGE PERMIT NO. �� VILLAGE IN A LLER'S NAME 6 ADDRESS Q U I L D E R OR OWN ER 0 DATE PERMIT ISSUED ip acl DAT E COMPLIANCE ISSUED IC' - 7 F '� �cv�cC.it rJ ice., a -79 i°tf '!Ono f2sa� PQF CihST �Cl' `�'O tn)�lj �, 2 +. r No i .~ ' a Fims......Sa t THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH O-WAv/.................of..&A94:5�...T..D.,V... RAJ1.7 16LC Appliration for Uiapau ai Works Tonstrnrtiun Frrutit Application is hereby made for a Permit to Construct ( V�or Repair ( ) an Individual Sewage Disposal System at: ............LOT 3 3 3 � � .. •.. s.. .��-- .... - -- ..... ... .....•- •- Loc on-Address or Lot No. A L1_iQ.c/ _ .457M.�,�J6.1 A/..._----- -------...•-•.............•-----•---......-••:..._.. w e Add e a ---- nstaller Address Type of Building Size Lot.Z9�_ �J.. ...Sq. feet U Dwelling—No. of Bedrooms............ .Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building _______________•-_.-________ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures ................ ................ d -------------•---------------------- W Design Flow..............J` 5................._gallons per person per day. Total daily flow...............:�3®.................gallons. WSeptic Tank—Liquid capacity/5'gallons Length_<>._'0_._ Wldthk..-O.._.. Diameter................ Depthle_•no.".. Disposal sposal Trench—No. ____._....•..-...... Width.................... Total Length.................... Total leaching area.................... ft. > Seepage Pit No......... ---------- Diameter_/_�__.-(i..._. Depth below inlet_*.q._`Q_. Total leaching area_.Z ....sq. ft. Z Other Distribution box Dosingitaank ( ) Percolation Test Results Performed by._C.�f'�E �. /. illL�S___ l�et�!/EYI.�,I� Date...j.Lm 1y.7,8_3.._.._.. Test Pit No. 1....... ......minutes per inch Depth of Test Pit.-1_--y___...___ Depth to ground water-------_______.......... (s, Test Pit No. 2._._._z.--_-_minute=_per inch Depth of Test Pit.._/_Y4�.___.. Depth to ground water........................ ---------- �.------------- -------- -------•--•----•-••----............................._..---......................................................... x Descriptipn of SoiV.0".-'/8 __ r ....... � .................................... Z. Y k_/ - ..... . 1LU4__..v1a� W ---------------------------••---•••••-•-•--•••-•••.._..---•--.-----••--•---•---•••.••-•-••••---••-•--............------......--••-•.••---------------•••-•••-----••-•-......................_......... U Nature of Repairs or Alterations—Answer when applicable.__......................... .. .............................................................. ...------•---•---••----•-•-••--------•----------------•--------------------•---•-.•--••- --....................................--•••-•-----•-•-•--------•-•----------•----••--•••••--••...------•-- Agreement: The undersigned agrees to install the afor de ribed Individual w Disposal System in accordance with the provisions of iITU 5 of the State Sanitary de— The under ' ne her agrees not to place th system in o e a C rtificate of Com fiance has tie n ued by Ae b I � ned. ••• ........ --•------ -----•--------- ...................--• ............... Date Application Approved By.............. .•--•-•------. •-•- ---•-•------ t® -,----____- Da Application Disapproved for the following reaso : .-••-••----=---•-----------•-•---------•---------••-----•-•-•--•---------------------•---•......•----..._--•--- ................••----•-••-•------------------•---•--•-------•------------•-----•-•--•--------------•----•---•-•---•-•-------•-------•-•----•---••------------•-------••-•---•-• ----------------------- Date PermitNo........ ':...._...."� �5-----•----------- _� Issued_---•-•-•----------------------------•------•------•--•- Date No.._.. .......... FEB U.......... THE COMMONWEALTH OF MASSACHUSETTS BOARD) OF HEALTH ..................OF..,�'.l: Al, TQAZ—../AJA:L_;�....::..&f Applirtttion for 11ispnsttl Works Tnnitrnrtinn 1hrmit Application is'hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: Z.oT• � ' �.�'���/ 10,27 �CAI .......... - ._..._... -- •-- .................................. ................ LoSation-Address or Lot No. --•--------•- -....._..4.<�_. �� �. ��f........ --•.....-•-----•--•--•-•-••••-•......-•................................. ............^ a ..............................Rt e •........Address ler Address Type of Building Size Lot Z .R 1_;?_.:f...Sq. feet Dwelling—No. of Bedrooms............. .............................Expansion Attic ( ) Garbage Grinder ( ) '4 Other—T e-of Building ersons_________________•-_-___-___ Showers LLI YP g --------•-----------•-----=_ No. of p ( ) — Cafeteria ( ) Other fixtures ---------•••---•---•---•--•-------••••...••. ••---•......•---••-••••---- --------------------------- - W Design Flow_____________ _ _____________________gallons per person per day. Total daily flow..._._._.._....J� ___.___.______.._.gallons. WSeptic Tank—Liquid capacity/ gallons Length:L..-. Width _.- ."__ Diameter................ Depthle'O... .. x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No........j----------- Diameter�R'._"_�72... Depth below inlet . !.`a_. Total leaching area..Zti6�0_....sq. ft. z Other Distribution box ( Dosingjta k ) aPercolation Test Results Performed by..(<n�9P......f_f �f?!b�C ... �!!�'_1f �1/.!�!_� Date... •/...../L-t-- _?..___._.. a Test Pit No. 1______ _______minutes per inch Depth of Test Pit__Iy`!......... Depth to ground water....... ""__---__---. Test Pit No. 2:..... :......minutes per inch Depth of Test Pit__l`1`a.________ Depth to ground water-.--_""..._......... -- ------------------------------------------------------------------------------------------- --------- -----•--------- ...........---•--••---........-•-•-••-- . O Description of Soils ' " � - Q1 .f ?L! ±45G?IG. /r, •� �E��/ =��( Qi_ t?✓ _, : 1 v #Z-.._ __.-.t.. ._. .... 1.q M. "D(1,1.+✓i ..a` !'JIB_._... 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 TITiZ 5 of the State Sanitary Code— The undersigned further agrees not to place the system in oo-- a C rtificate of Com fiance has been issued b the board of h gned Da Application Approved By-•-•---•-•--•--•-•••-•-----••-••-••--•-- f ..... LID e Application Disapproved for the following reaso s: ............................................................................................................. ..............•--•-----••----•••-•------...•-•--•...----•---------••-••••--•-••-•••-•-•••--•------•-...--•--•---•----•••---••••••---•---•--•----•--•---••------•....................................... Date Permit No..... -- !•_+a.................. Issued Issued----------------•----------------------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .........................................OF..................................................................................... farrtifirttte ,af f��ant�littnrr - T I IS TO C� 1 Y That th Individual Sewage Disp s 1 System �coj structed (X) or Repaired ( ) by-, ^g 'Q't - "o �: i L+i S/�/Sri ----•---- ��`'`��c/� ,�<y4�-5_ ............r.. ••-- . Install 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 Perpiit No......................................... dated------------------------------------------------ THE ISSUANCE OF THIS CERTIFICATE"SHALL.POT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE... ._.._..�.Q•- = .. ..... .._...---- Inspector .................. THE COMMONWEALTH-OF MASSACHUSETTS BOARD OF HEALTH ' r /� C No.:�...................3 ` FEE....�....._.......... Re o� oL (�'-v gE Rts �a�tt1 �r�� �rrn�ti` timrn rrutit n ��L`Rts ermisslo is hereby granted ............. ... J to Construct r or Repair ( ) an Individua pwage Disposal System f.. 1....._. x Street as shown on the application for Dispo al Works Construction Permit ... Dated...... _1�.�: ............... �4 IILT � Board a lth 4 .. DATE--------------- ------- ------=---..•--•--•--------'�---- .....'.......... FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS SYSTEM PROFILE NOT TO SCALE TOP FDN. /-FINISH GRADE 9.5 U FINISH GRADE 0 VER FINISH GRADE OVER DIST. BOX - '. ra'.".' FINISH GRADE OVER o:a a'' SEPTIC TANK_,:�O L EA CHING PI T -+- ° °.. VARIESXVw O.4. -v. 0 . : ' ' bO` O;aD: OB:A: c'.flV: A4o OF " — 1/244' W 1/B " 12" PRECAST CONC. OR a o WASHED PEA S TONE �• BRICK 6 MORTAR ° = p OUTLET PIPE LEVEL S TO 12" BEL OW GRADE FOR 2 FT. MIN. .771 v:4:a'.o b: .:' am r'.o dbo b Q -4•ip.`a:o,o;a.I _o C. I. OR PVC TEES ° 1 . 43 it c41 10a: BSMT. FLP. o o:o':D': v �' .�' co GALLON Q: DISTRIBUTION BOX t= O r PRECAST CONCRETE INSTALL ON LEVEL BASE WASH TO 1-1/2H + "�_PRECA ST ° I WASHED . • H— /0 REINFORCED CRUSHED V CONCRETE STONE n •.c�oQd A��a��.G¢Ap:Q'°o o:P.O.o�ab:�•{s-4:°Q:oQ�'Q.ea��oo I - � H— j \ , 0 REINF. SEPTIC TANK a:':• ' INSTALL ON LEVEL BASE �+ oa a.�. . ° �� o Q A� �• NO EXCA VA TE TO ELEV. , 6__pA LOWER TO REMOVE ALL IMPERVIOUS MATERIAL BENEATH THE LEACHING AREA 5 2 z e,' Y y REPL A CE EXCA VA TED MA TEAIA L WI TH CLEAN, CLAY FREE SAND �• V A G AP-S-' r EFFECTIVE "DIAMETER r GENERAL NOTES LEA CHING PIT 1. ALL EL EVA TIONS SHOWN ARE BASED ON r l,N`. INSTALL ON LEVEL BASE 2. ALL PIPES IN THE SYSTEM MUST BE CAST IRON OR SCHEDULE 40 PVC. 08SER VA TION PIT 3. THE BOARD OF HEAL TH MUST BE NOTIFIED 2/L ,r WHEN CONSTRUCTION IS COMPLETE PRIOR .rsoo sAccaw TO BA CKFIL L ING PERCOL A TION RATE.' % MIN. AIN. PRECAST CONCRET 4. ANY CHANGES IN T T HIS PLAN MUST BE APPROVED r� SEPTIC TAW y =� BY THE BOARD OF. SAL TH AND CAPE 6 ISLANDS WITNESSED BY.' SURVEYING CO. , INC._ . • 5. MA TEAIALS AND INS TALLA TION SHALL BE IN k f; �j COMPLIANCE WITH THE S TA TE SANITARY BRO.. OF HEAL TH DESIGN DA TA d DA TE.' �9 CODE — TITLE V — AND LOCAL APPL ICABL E RULES AND REGUL A TIONS , _y �t _ 5 NUMBER OF BEDROOMS _ 6. NORTH ARROW IS FROM RECORD PLANS AND - '' ' �`o IS NOT TO BE %JST D FOR SOLAR PURPOSES t -- GARBAGE DISPOSAL YES ��-'�,.• 7. FLOOD HAZARD ZONE GPDDAILY FLOW wt` B. WA TER SUPPLY l E;0 0 SEPTIC TANK REO D GAL SEPTIC TANK PROVIDED GAL Sao � PfaECAST CQNCNETE r I.EA CHIN ST PIT \ p 4R LEACHING REQUIRED •-- GPD V A�Ati•T � ...�.� p -� . rr. _ SIDEWAY %AREA S.F. S. . X G :� S. F. = GPD. � �O 0 LEGEND BOTTOM AREA 12� S. F. a Q3 S. F. X GIS. F. = 23 GPD <• tiQ - _�''' LEACHING PRO VIDED 'En { 6 GPD AT 2 i 4 4� �, o w A.TcTZ PROPOSED EL EVA TION 3!9.r .:---- - -- -- EXISTING CONTOUR SINGLE FAMIL Y RESIDENCE 9 OBSEAVA TION PIT ❑ DISTRIBUTION BOX ' PROPOSED SEWAGE DISPOSAL SYSTEM •� 7 yi,Robf TS c£D G ' P;T O LEACHING PIT F' No �.4 PREPA RED FOR I ar` C�v;q iJ W1 f o� S h w) U- jS w � 8- E,2J£u P>�c:r.� o o SEPTIC TANK MA L KON SHEMEL I GIA N 1.1001 RESERVE PIT AREA LOT 333 BLACK THORN LANE &AV D PIPE INVERT EL EVA TION ���"��-- BA RNS TA BL M. M L L S MASS . DA TE: CAPE 6 ISLANDS SURVEYING, INC. PLOT PLAN SCALE A S NOTED SCA L E.- 1 P. 0. BOX 334 MAP SEC PCL LOT HSE ' . PLAN No. S �15 5 5 TEA TICKET, MASS.