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HomeMy WebLinkAbout0095 CAMELBACK ROAD - Health 95 Camelback Road Marstons Mills P 064089 i nn SEWAGE INSPE TIONS h LOCATION q��C.f�m(� ,rG RC1Q( DATE VILLAGE_MQP6f"0nS rnJ►I ASSESSOR'S MAP & LOT®b 0 %NSPSCTOR AoDbe&PQb/i C, SEPTIC TANK CAPACITY /000 6611m LEACHING FACII.ITY: (q'Pe)/ cAj)Q pi�- (size) /6too GCr&" NO.OF BEDROOMS 3_ BUILDER OR OWNER JO1# >°rCiA. OWNER MAILING ADDRESS f r r 16� l� �,� calinel oac 4cl DATE_9/_9 3104___ PROPERTY ADDRESS: 9 5 Came e&ack_2d.,__ Mae,3t on.6 m iaz, Ala. ----0 2 6 4 8----------- FRECE'VED] On the above date, the septic system at the above addreInspected. 15 20This system consists of the following:. F BARNSTA1. 1-1000 ga-eion �3ept.ic .tank. LTH DEPT. 2. �-d.i.�5ta.i�ut.ion fox. II 3.4-9000 ga-e&n eeach.ing /z.it., Based on Inspection, I certify the following conditions: 4. 7h.i6 .ins a t.itie 4ive he/�t is �y�,tem (78 code) 5.'7he be/zt.ie byhtem -ib -in /?20/2e2 woak.ingoade/t at the he, pzezent time.' 6,,0as"te wati_a in ie.ach.ing • p.it wa,3 29 9eiow the SIGNATURE• Name: Rogeat Pa 'Iini --____-- Company:—:--ap_(9acom&ea_and zon, Inc.- Address:_i_0._B 6 x— 6 6------------- -AP -)ARCEL, ' O Centeav i p ee (7a. 02632 _4T ( 508)775-3338 Phone:--------------------- THIS CERTIFICATION DOES NOT, CONSTITUTE A GUARANTY OR WARRANTY JOSEPH P. MACOMBER & SON, INC. Tanks-Cesspoolls-Leachf ields Pumped & Installed Town Sewer Connections P.O. Box 6775.333tervi7e, 02632-0066 COMMONWEALTH OF MASSAMSET TS mom_. EXECUTIVE NM''� OFFICE OF EI"MR6NTAL AFFAIRS A DEpMITMEN'. 'OF NV1 QI�NfEN'1`A3�pR,pT CTION r G y 'TITLE 5 .. RY OFFICIAL INSPECTION FORM—'NOTFORVOL1�}NT SYSTEM FORMNTS SUBSURFACE SEWAGE DISPOSAL PART•A CERTIFICATION. 95 Carneeelack Road Property Address:'• zzt7n a Owner's Name: 2r�meh 2arin Owner's Address: Date of Inspection: Name of Inspector: (please print)R o•P z la %,u o i_ n Company Name; ?.=( atom a e�' .SAn Inc. Mailing.Address: Cen envy Q. abb••02632 Telephone Number: 5 D'&-7 7 j 3 3 3 CERTIFICATION STATEMENT have personally inspected the sewage disposal system•at this address and thae �e d b sed on my reported I certify that I h p below is true;accurate and complete as of the time of the inspection.The inspectton�was p training and experience in-the proper function aon.15 340 ofT,itle S(31 CMR 1a:a00)a . antsystem'systems.I a DEF . approved system inspector pursuJVV ant to sect Passes Conditionally Passes Needs yurther Evaluation,by the Lncal Approving.Authority F .'Is rn Date. Inspector's Signatmre: ectinn re on to the.App"roving,Authority{goard of Health or The system inspector shall submit a copy s this inspection. p. within 3U days of completing this inspection,If the system iJs.a,shazgd system or has a design flow of 10,000 DEP). p pp gpd or greater,the inspector and the system Owce of the ae`rMse�shall"submit pies sent to the buyer,f applicable l and the l approving DEP.The original should be sent to•�tho system o authority. Notes and Comments **** only describes conditions at the time of inspactldn and under the conditionsthe same or,different 'phis report y ^ time.This inspection does not sddress how the system will perform in the future u conditions of use. naae I Page 2 of 11 OFFICIAL INSPE,CTION:FORM—NOT:FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART'A CERTIFICATION (continued) Property Address9 5 Came U a ck /2o ad aaz one (7� Owner: lame-6 Pltacla Date of Inspecti A N « Inspection Summary: Check A;B C;D or.E/AL_WAY'SEcomplete<all of Section;O A. System Passes: n o 1 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: The 3epjic 3y.6.tem i, in /21tope2 wo2kirzg o/tde/ta.t i-he' .../2/tezent .t.i.me.! B. System Conditionally Passes: no One or more system components as described in the"Conditional:Pass"section.need to be replaced:or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not.determined(Y,N,ND)in the for the following statements.If"not determined"please explain. N The septic tank is metal and over20 years old*or the septic-tank(whether metal.or not)is-'structurally unsound,exhibits substantial.infiltration or exfiltration.ar tank failure is:imminent. System will pass inspection if the existing tank is replaced with'a complying septic tank.•as-Approved by.the.Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not Jeaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: NO 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(with approval of Board of Health): N A broken.pipe(s).are replaced. . N 4 obiftetion is removed _ALA distribution box is leveled or replaced ND explain: Nf! The system required pumping more than 4 times a year due to broken or obstructed pipe(s)4 The system will pass inspection if(with approval of the Board of Health): _N broken pipes)are replaced N,/ obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM-NOT VOR VOLUNTARY ASSESSMENTS SUBS>tRFACE SEWAGE DISPOSAL SYSTEM INSPECTION f ORM PART:A CER.TM CATI ON(toritinued) Property Address:9 5 Cameiga ck Rcrad Ownen-jarnez %riza n Date of Inspection: 9/ 4 r C. Further Evaluation-is Required by the Board of Health: no Conditions.exist which require further vvaluation.by.the,Board.ofHealth;in-order,to Adtermine if the system is failing to protect public•health, safety or the environment. 1. System will pass unless Board aWealth determines4h 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: NR Cesspool or privy is within:50 feet of aswfice water NR 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 Supplier0f any)determines.-that the system is functioning in a mariner that protects the public health,safety and environment: _!no The system has a septic tank and soil absorption system(SA•S).:and the SAS is within 100 feet.of a surface water supply or-tributary to a.surface water supply. n o The system-has a.se tic tank and SAS and the!SAS is within a Zone 1 of a-public water.-supply. - p and SAS:and-the-SAS is within:.50 feet of a rivate water supply well. n e The system has aseptic tank A !. rr y n 0 The system has aseptic tank and SAS and the-SAS is less than 100 feet..but 50 feet or-more ffonl a private water supply well". Method used to determine distance, m p rl.A um P r/ **This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from-pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5.ppm,provided that no other failure criteria are triggered.'A copy of the analysis must be.attached to•tbis form. 3. Other: Page 4 of I 1 OFFICIAL INSPECTION FORM-NOT=FORNOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 95 CamP_9P.ezrk• Re)rjrl OWner:aamez %/za a Date of Inspection: 9/13 70 ' D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to.each of the following:for.all inspections: Yes No x Backup of sewage:into fa ility or.system component due.-.to 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 thank"below invert or available volume is less than'h•.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 x Any portion of the SAS,- cesspool or privy is below high ground water elevation. _ x Any,portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion.ofa cesspool or privy is within a-Zone l eof 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 l 00feet but greater..than 50 feet from a.private water supply well with no acceptable water quality analysis. [This system..passes if the well water.analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution.-from.that facility and..the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are-triggered.A•copy of the analysis niust be attached to this€ortq.J NO (Yes/No)The system fails.I have determined that one or.more-of the:above failum,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.ataeility with a design flow of 10100.0 gpd to 15;000. gpd• You must indicate either"yes"or"no"to,each of the following: (The following criteria apply to large systems in.addition to the criteria above) yes no 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 II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a sign.ificant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the,system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional.office of the Department, 4 Page 5 of I I OFFICI•AL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS r' $LtSURFACE SEWAGE DISPOSSAL�'SYSTEM INSPECTION FORM PART CIiECKLIST PropertyAddress95 Came.e&ack Road altz on,5 m2.iiT Owner:.Iamez l2ada Date of Inspection: �3:/0 4 , Check if the following have been done You must indicate"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 Were any of the system components pumped out in the previous two weeks? x Has the system received normal flows in the previous two week period? - 1 x Have large volumes of water been introduced to the system recently or as part of th{�sinspection? x Were as built plans of the system'obtained and examined?(If they were not available Mote is N/A) x _ Was the facility or-dwelling inspected for signs of sewage back up? x Was the site inspected for signs of break out? X. Were all system components,491"ding the SAS,located on site? x _ 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? x — Was.the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site-has been determined based on: Yes no plan at the Board of Health. x _ Existing information:For example,a p _ x Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] . 5 Page 6 of 1 I OFFM? IAL I NSPE4E�'FIO I::IF',QRM'-NOT FOR VOLUNTARY ASSESSMENTS SUBSU9FACE SEWAGE D1SI OSAL�SYST9M JNSPEETJOL, FORM PART.0 SYSTEM.INFORMATION Property Address: 95 Cameigack Road Naaz.tonz 11.i.e.ez Owner: Iamez• P zada Date of Inspection: , 9 44 , FLOW CONDITIONS RESIDENTIAL Number of bedropms(design): ,=3 .. ,Npmber of.bedrooms(actual):3 DESIGN:flow-based on'310 CNIR 15.20� (for eXaiiiple:'1 I0'gpd z#-of bedrootiisY: Number of current residents: .,2 I7oes�tesidence have a garbage grinder(yes br nod 2 is laundry on a separate sewe.3' stem(yes or.no):n o (if yes separate inspection required] Laundry system inspected(yes or no): a'o SeAsonaluset (yesorno): no 2002-90,,000gaiion6 IgPD=246.• 57 Water meter readings, if available(last 2 years usage(gpd)):i n n 1-4 6,_ 0 0 9a U o rz.3 [fit 12 6.,0 2 Sump pun (yes or no): n o Last date of occupancy: R a e.3 e n t COMMERCI;A.L'a, USTRIA•L Type of estahnt: NR Designflow. �� `�A on 310 CMR 15.203):. AIA gpd- Basis.of d4igii'`flow(seats/persons/sgft,%c.):, NR Grease trappresent(yes or no):7V R Industrial waste holding tank present.(yes or no):N,4 Non-sanitary waste discharged to the Title 5 system•(yes or no):N Water.meter readings, if available:NA. L;ast'date of occupancy/use: . N,4 OTHER(describe):. NA 'r�sENERAL INFQ A-T Pumping Records 1119198- 10125102 12umled boa main.t gy �.-P, Nacomgea Source of information: Was system pumped as part of the inspection(yes or no): n o If yes,volume pumped: NA gallons--How was quantity pumped determined? NR Reason for-pumping: NR TYPE OF SYSTEM , Septic tank,distribution box,soil absorption aystetn 1ta Single.cesspool n o.0verflow cesspool n.a Privy Shared system•fiyes or no)(if yes,attach previous inspection records, if any) no Innovative/Alternative.technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) m n(Tight tank. !Attach a.copy-of the DEP.approval n o Other(describe): Approximate age of all components,date installed(if known)and source of information: 20f tieaah Were sewage odors detected when arriving at the site(yes or no): n o 6 _ Page 7 of 11 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:95 CameiPlack Road Nazzston.6 Pl-ie-9�s Owner: amez laada Date of Inspection: 9/13/0 4 BUILDING SEWER(locate on site plan) Depth below grade: 16" Materials of construction:_cast iron x 40 PVC_other(explain): Distance from private water supply Sell or suction line: 0 Comments(on condition of'oin ,vet�, vidence o le ka . e c.) aointz ate tcyh rventerC h2oug�Z �Zo ir, dent no ign� ,off . .eeakage. SEPTIC TANKS(locate on site plan) 1000 ga.P e o n Depth below grade: 18" Material of construction: x concrete_metal_fiberglass_polyethylene ather(explain) If tank is metal list age:�a Is age co nfnxned by a Certificate of Compliance(yes or no); —(attach a copy of certificate) Dimensions: 5 ' 6"Long 4 ' 10"Ni.de 5 ' 8"K.igh Sludge depth: t 1t a c e Distance from top of sludge to bottom of outlet tee or baffle: 0 Scum thickness: t a a c e Distance from top of scum to top of outlet tee or baffle: 0 Distance from bottom of scum to bottom of outlet tee or baffle: How we're dimensions determined. m e a z u a e d Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural irate as related to outlet invert,evidence of leakage,etc. : �ty>liquid levels Pam evelty. Z to 3 yeaaz., IM-t 9 outtet teen ate in N.eace. lank i.6 .6tzqc;tu/taiey zounZZ, t7tqa2Z1. :teL)e_.r_',0 No h.ignz oZ .Peakage. GREASE TRAP: N,40ocate on site plan) Depth below grade: Material of construction:_concrete metal fiberglass (explain): N R polyethylene_other — _ Dimensions: NA Scum thickness: NA Distance from top of scum to top of outlet tee or baffle: N,4 Distance from bottom of scum to bottom of outlet tee or-baffle: N4 Date of last pumping: N,Q ®� Continents(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage:,etc.): aea-6e taaR .i.3 not ,1 ent. Title i Tnennrtin»Fnrm 6/1;ionnn 7 Page 8 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS 50*8-RFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 95 Camei ack Road owner:aamez P)za Date of Inspection: 104 A TIGHT or HOLDING TANK: no (tank must be pumped at time of inspect ion)(locate on site plan) Depth below.grade: NA Material of construction: concrete metal fiberglass____polyethylene_other(explain): IVA Dimensions: NA Capacity: NA gallons Design Flow: NA gallons/day Alarm present(yes or no): NA Alarm level:IV A. Alarm'in working order(yes or no): Date of last pumping: NA Comments(condition of alarm and float switches,etc,): l i gh t nil h n�I�a(nor/ f�i n l�Q �i n g—L�4-�—^,-:n-4 8P .' DISTRIBUTION BOX:ye'3 (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.): Box haz one iateaae- No .s-i n.3 o zotid caAa ovea.4o 6.i ns pj Teakgz zn o2 out o ox.. PUMP CHAMBER: No (locate on site,plan) Pumps in working order(yes or.no): NA Alarms in working order(yes or no):NA Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.); PumI2 chainae2 .!,s nn.t- ,?aaAenf vn 8. Page 9 of 11 OFFICIAL INSPECTION FORM—'NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 95 Cameigack Road a2.6.t01z.6 uTez Owner:aame_s 1 as a Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Se Type y e z leaching pits,number: no leaching chambers,number: n o leaching galleries,number: no leaching trenches,number,length: no leaching fields,number,dimensions: no overflow cesspool,number: n o innovative/alternative system Type/name of technology: ,Comments(note condition of soil, signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): Lomay .to medium .6and. No 6.i ne eye . a con �z noamai., CESSPOOLS: NO (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: NA Depth—top of liquid to inlet invert: NA Depth of solids layer: NA J Depth of scum layer: Al A Dimensions of cesspool: NA Materials of construction: NA Indication of groundwater inflow(yes or no): NA Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: NO (locate on site plan) Materials of constructionNA Dimensions: NAA e Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): l2.iv .i-s no.t aeZ 9 f Page 10 of 11 OFFi HAL INSPE4CT'TON FORM,NOT`<FOR'VOLUNTAR'Y.ASSESSMENTS E h'AGE,:DIS�P.QSAL SYSTEM-.INSPECTION:FORAY ; S5IF ACE S PAR • T C �. SYSTEM INF-ORIYIATI.01'�1(continued)` Property. Address: 95 'CameiPack /Road ia2� one 77776 Owner: Jame- l-2a a Date of Inspection: SKETCH OF SEWAGE-DISPOSAL SYSTEM ovide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or bendhmarks.Locate all wells within 1.00 feet.Locate where public water supply enters.the building. shy � lei \ 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 95 Cameeeack Road Naar.t onr N i 2.Pr Na Owner:aamer 12ada Date of Inspection: 0 4,. F' SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water)' U feet Please indicate(check)all methods used to determine the high ground water elevation: n 0Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentatippn) _ye,3Accessed USGS.database-explain:hi_i/2•'town gaanr.tagte.-ma.•uz You must describe how you established the high ground water elevation: and m"iiiea model 12116194 � aound wr�tea a&ove rea �eve� a APr/ •7or'hn"ica.L gu te.t"in 92-000-1 R.eai_e#2Jan. 1992 annua ganger �.��nntlnl� nn.�y .Qeya.t"(.Onr Ground Leaching Pit 'eet Groundwater: Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per FrimpLjr Method s Therefore,the vertical separation distance between the bottom of the leaching pit and the adjusted groundwater table is feet. 11 DOARD OF 11EALT11 'TOWN OF SWISU11FACF SEWAGE I)ISPOSAL SYSTEM INSPECTION FORM - PART D - CEIi'fIFICATIrONr� _.•� �..:-::.--.,r.-.•r.•:-r+mr�•rt:esrirnrrms+sm�+n'*"�•'•-rrtvtnrarn�'�°0� �" -TYPE OR PRINT CLEARLY- PROPERTY INSPECTED , STREET ADDRESS 95: Came-9Paek Rd., ASSESSORS MAP , III Q.,CK AND PARCEL # 064-089 ` OWNER' S NAME Ja.me15 lzLgda PART D - CERTIFICATION NAME OF INSPECTOR i2g&e2 - COMPANY NAME. Joseph P. Macomber & 'Son COMPANY ADDRESS B�66 Cent To, , cr city State LIP Street COMPANY TELEPHONE ( 508 775 3338 FAX ( 508 .� 7 0 CERTIFICATION STATEMENT I certify that I have Personally .inspected ith sewage distegaansystem' at Or his address and that tli.e information reported omplete as of the time of �inspection , The inspection was performed and any nt ecommendations regarding upgrade , thenprooperefunctionrepair and maintenance ofon- with my •t'raining and experience in site sewage disposal systems . Check one: VV A_ Systeln PASSED not found any infrmatio The inspection which I have conducted tosadequately protectopublicn which indicates that. the system fails Iteailll or, file enviro:�:)mer)t as det tad in ailure the FAILURE d in 310 CMR. �CRITERIA 03 , Any f section of criteria=not evaluated are as s this. form. System FAILEll* The inspection which I have con Lcted has found that the system fails to Protect the ���Iblie health and the enirnotedtotiinPART accordance �ILURE 'title 5 , 310 CMR 15 , 30.31 and as specifically CRITERIA of this in ection rm . Date o Inspector Signature- copy of this cert.tficatio•n must •be provided to the OWNER, the DUYER One where apP11cable ) and the DOARD OF HEAI+1'it. ,, . * ator l d If the inspection FAILED, th'e owner or op°runlessallowedgrtrequi. edhe m within obe year of the date of the inspection., otherwise as Provided in 3Jo Chln 16 . 3.06 , partd .doc T BARNSTABLE LO ATION 1a,,,,,71.7 ld SEWAGE # VILLAGE j45 ASSESSOR'S MAP & LOT 0 QNSTALLER'S NAME & PHONE NO. EPTIC TANK CAPACITY 0 00 ft LEACHING FACILITYAtype) (size) 00 10. OF BEDROOMS PRIVATE WELL OR UBLIC WATE BUILDER OR OWNER Cd�4 . DATE PERMIT ISSUED: �� s DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No f a 0 At i7 t � a No - .......... Fins. . THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEAL) .------. ---�'��..0F....... .. Applirtatiun for Disposal Works Tunutrurtiun jhrmit Application is hereby made for a Permit to Construct (-)'f or Repair ( ) an Individual Sewage Disposal Syst at: Location-Address or Lo No. T I ?, _T..RrG7.L[t 10 ., 6f �YG41/. 1 ....-•--- -....... ---- a .............. r_i10.... 7.E Q .W. .A1..-D.1,-j .................. t �'t �Ad 2...!1_-.........------•--•- Installer Address Q Type of Building Size Lot_, /__d-_-I.Sq. feet Dwelling—No. of Bedrooms.._ ...%?----------------•--------_____-_Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building 00 . o. of persons.......... Showers ) — Cafeteria ( ) Q Other fixtures _ --•------------------------------------ Design Flow................ gallons per person dap Total d it fl _ _______________________ rrs. w -- p "1...----- l� o W Septic Tank Liqui capacity./40gallons Length__��___�_.. Width.. ��Diameter................ Depth... x Disposal Trench No. ................ Width........I.......... Total ) ength............ Total leaching area..... _....sq. ft. Seepage Pit No..........I......... Diameter----------4------ Depth below inlet...... Total leaching area.._•` sq. ft. Z Other Distribution box ( r) Dosing tank ( ) aPercolation Test Results Performed by.__ .._,L,I�C��,(�/--R.J111.4......... Date....... _ . - Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water..__ Mgrr�___ f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water/v!°�°.�7� R1' ! ��....J J r --- x Description ofj Soil_ Gl lac•c-- � l u ------ ----- f� -................................................ ------------............................................................0 •-------------•-.-•-- VW1.? D W--- = ----------------------------------------------------- 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'I U 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 boa d health Application Approved By......................................--=--•••- ............................... ------ ��Date Application Disapproved for the following reasons-------------------------------••---•-------------...----------------------------•--------------------•••...._._. .............-........................................................................................................................................ - Date Permit No.---•--•-••-••-• �y Issued_.2-. Vnj�. ............... 9 W Date r No... .... SS c Fps. .........._ R THE COMMONWEALTH OF MASSACHUSETTSS�e.C� BOARD OF HEALTH i , pplirtttion for Piipuottl Workii Tonotrnrtinn Fumit Application isyhereby made for a Permit to Construct (J-) or Repair ( ) an Individual Sewage Disposal System at: Location-Address i or Lot No. ! �r r ..r.,`i fir. - / %:. s.�_- Y T f k-17-7 �� -/ --;/ .... _ ...- ...... -•----..... •--•---•-•----•---------------•-••--........-- .... . ... Owner A . Installer Address ���r� G ` / . Sq. feet Type of Building Size Lot_:____z:___.__________`' _ aDwelling—No. of Bedrooms______'f_________________________________Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons........... _:____________ Showers 0 = Cafeteria ( ) Otherfixtun-:----•---------------------------------•-------------....................................................... ....____ allons per person er da Total it flow.___._.__ W le Design Flow ` r g P P al P Y Y •=�---.................... Ions. ' p; Septic Tank—Liquid capacity_:�r h" gallons Length_ ....:?_._ Width._ m Diameter________________ Depth W , T. P �, ^-' x Disposal Trench—No...................... Width____._.y'.......... Total Length............ Total leaching area..... v sq. ft. Seepage Pit No..........I--------- Diameter........._...... Depth below inlet...... Total leaching area ^ ..^f.sq. ft. Z Other Distribution box ( j) Dosing tank ( ) �-7 Percolation Test Results Performed by-__;�.n ?:'..._ ._!..'./_!:!✓� ;•..j f.._._____ Date_______ ..�`_ a Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water..= Ars . .. GL, Test Pit No. 2-----_........._minutes per inch Depth of Test Pit.................... Depth to ground water.'.Yfr/`...... / } ar + -- ..:............. -O 'f l,/fs /� : -7-----•-•----------•-- ------------ Descriptionof ---_•„ . U -•---•-•-••-•--•---•- •-------.......................................................= ---••-- ------------------------------------------- •-•••-------------------------- A' IV _J................. _ _ ____________2 ` .________._.._________._._.___.______.__.______.____.___.__._.__-_.__..__.________.......__ 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 aCertificate o has been issued by the boar-,d.of'health �mplianc ne "` � �� �� r ''�-��'`/�`''��-��'--y_r- ,l. ,,,,,,�,�••----�•� atel ~ Application Approved BY_..................................... Date Application Disapproved for the following reasons--------------------•-----._...--••------•--------------•-----------------------------•-•••--••--•••-------_...._ --•-•-•.....................................•--•-•-----•-._...__ ----�-------------------------- Date Permit No.------•. :. ........ Issued_"`'_ ..._ -Date"` -------•--_..._. 40 THE COMMONWEALTH OF MASSACHUSETTS �-! - BOARD OF HEAL / .......f. ..0F....;!.,f. f?, ... ............. �rrtifirtt�e of f�unt�littnrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed W-) or Repaired ( ) .�� 1)by r 1... ..! l .. .................................................................••---•--•---••-----•-- a Installer at;::._.._.. -- --__* � •----•----_---•-••--•- - .-••_--_-----_-•••-'•-_---------•-_••--••__•- has been Installed in accordance with the provisions of TITLE 5 of The State Sanitary Code s described in the application for Disposal Works Construction Permit No..... _ »- date _-_ ............... THE ISSUANCE OF THIS CERTIFICATE SHALL. �OT BE �+ISTRUED AS A GIJAHAT THE SYSTEI`+11 . LL FUNCTIONS TI'SFACTORY. +� °'" �1 DATE.. `'y -s p rS % L _�___ 1 -• --- --...-•••----...--•--•-----•--•---. Ins ecto ... _ .__._ ffi:... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .........' ..... ......0F.......1 .. .t ......_._. -7 ,�7 ...�..( 0. Disposal Works Tonstratittn Prrutit ,}Permission is hereby granted__... to;,Construct ( ) or Repair ( ) an Individual Sewage Disposal System Street as shown on the application for Disposal Works Construction Permit N -. Dated _ _, _j .--.--- ................L __� ___ ___� _._......._..___„ I# Bokrdot�He ala DATE. "'. /}. ..._..._.. _�� FORM 1255 A. M. SULKIN• INC.. BOSTON to PI T _ RE �„ per//�, �p ol / • r�lTC A4 ' /IYE d ✓111V;, Icll F �/ y� � t_ � -� r ai r i r � � � U� � r \� � �} � �� „//1+'� ��S C1 Tr��R��;�E 6RAE-CIFIEP 11EV�UN� b _ ft i1 t �4 � t �, AI-L PIPE, TO ANP tN T14E SYSTEM BE C'.457' .I,RC� OR SC1-/E.P411-E •40 PVC. 77- tit t�`J 4 ' P7'f r" T lv /�7RI T/ 7 O. E, '�`1V p E.4CI11r�-6 P1 TS SH,41,. 6� { C�.C3 (D0000) CEO d FOR ZO krll ,Cl- 1,O.4P PING WA IV (D 0000 (DO ,� 1 {:. - SEE , L IIN a5t1I r , �A TR,3'. I TT_ _r_ ,: - VJ �,}Ei 'E.r4 TII TeVE 1NI"EI?7 1 S AIJ t7 _ t 1 r0 „_ i +'r �v a L� vJ F TEE 6F 1 , C '� FOR A P/6 U NC E O.�" C./. SAN/ Is Y 7EF rA 1� ANC eACKFI.-A', WITY CLAY- CJ C� CJ r✓ r lv vE/ 4v>N6 A PERC04,QT.ION- s Z r YRICAI., PISTRIB IJ77 AI 3CO J , r ,a T ,� �, Al1N1-17 ,5 P�:R IIvC H OR 4,655 /VOT rO SC,44,E TYPICA,I. ZEgCN T/NG P/ rfA"' NF'A•L rH.VlIST 1vO7`E P1,5TRIBIITION BOX AIVP/ G 91 NOT TO 6C,41-E BE NOTIFII-- ` WIPE Al TNEx �YST�*15 1VEAR 0 ER T/CIN PI b RE1/11FORC'EG' S8"pTIC TANK 5y , C'010,P-ET/ON 4AP /-W,'`Ci 1 " A '; j � WIG TY 'IG',4,�. v ,. SEPTIC ?�: l llC '7 lIN4E,SS O rxE R 15E NO SE 44" 15X.5rE. � A/i?'ER/C'AN t',IPEC,4ST 0/4? EQ11A _ IVOT TO SC _ C01WRONENi-75 � ,3E I!VST I `.r' NOTE" T,41V t' :l'E1/VF01?C6-p THROIIGHOIUT ,4cCow-4P,r4NCzE` 11,11TH TIT4,E ,0,1 TIIE'>,5Z4T� W/TN E4ECTRIC WE•lI EP f 'fi'}' W/Tf11 Z4 - %le, / S.�'tN1TAft'Y �bt��'E ANt.� .�`,/li';✓ �,t�r,r4.�. A11I. E5 A 'OW t i I E RI/s` � ,'i'v"C t iL/BFG'1�12 ST,E� +'O!'S 111d IC7P c 0 ,/YH/C :�f?' Y .fit 'f',Y T - 5�*D7- 1 -7 CONCA' 7-Z- /6 4,000 PSI r.<_-- A/OT,E ACC E55 AfAN1-10L 5 TO 5EO r D 7-0 AN,,' � -�/ c a�► A ND 1—,EACN PVO P/TS TO 3,E �301� T U 1-49 ,1f,!V1.SN SRAtE C� ;-FINISfl vft'A,G ` OxcR T,4NK F4Y H� GXE F/N15H 0,e,40,E OVe. ? z-ZEY _ fO n ECEY /NG �''1 T or qga7r Coco �a�Gt? t`-- �( __ _..__-J_ NY'=44+ too ' : ' i o�� '1 1 v„ 3 r� {-, �- � r.-4o I 1N1ry 444TS �coa c r4 G, 1Nl% _ 6° +?) 0 8 c� 3 �p �---- G7F /� 1 E 4t9G'tiSTt`JX o ovo :y RF,%!✓ C?RCEO c 0 � rJ �ja o � QCISHEO STCN� c (,t �c ! (r} O o'vy°3 �� U � ' a 0 e 0e D 1 1 h Y- F- •I! (rts BE �,.E4E.� �' ST.4BC�;? -----�.--� � /4 TYPICAL 5EWAC7F 5Y5TEM P 0�7L NOT TO 5CALE: SAP sE`c r14N PARCEL, kO T AvvR6ss ,o j .ram _._•_ 1 � fir____-: .. LE�Gtfl AJG �r \ , `p�V/r1lG P1,SrRICr' Fl-00P r'�,�4.�.9RP .�"O/VL4- i f�FS/GN CRITEfi'l, ,�EGE�vv f' 'C P « E '� O�" 1�YE ZING NUMBER Of BEPROOM.S _ :_ FX/5 T CON T JU, ' E/IA6E 1,.5P A SYSTEM TL I�'! PERSONS PER CE©ROOM .�'/i�opo, .SE`1% CONTOUR � ",� CrA k l.41 6 PER PERSON PER. SAY EX 1ST` SPOT F_k EVA TiO N 6*0 ti 1` - - AC � _ C��A C) A',EACN11V6 REQUIREP V � I 0141e),56P 5/107-�,EVATION c3�O � :: � (� a v ;- �t� I-EACNING PRO M/©E f� `_ PERC04 A TION TEST m No P15P05AX, 0,Z3SERi1AT14N P1T / 4�'P4IC4NT ' F dGINEER T . : 'ROW ENGINEERING INC. SE�Y,EI� f�ES/G1� .. ,,. ��. yAe►�v-�d, r- t�. : ���G,�lfJUTN,��l.�,75,�. :. S/DEWA,Cr�.,• .. P .,I,rt`t ;t Irt,t�, : � °;� „.. �`-% �° � _ ' _ r t/ ^ �1 •�- Lam+ y .4S NtJT�'f�' rr .•. .d• �j�/t �/ �,/ f �_+ y fig... �r�g �j pTO rAk ` ��y� ' i�'I7 4W O! :. 'L mow+: Ii i�6.� .°�' l'�Y e s F'�4�N r .Jr ... 1 , }