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HomeMy WebLinkAbout0221 CAMELBACK ROAD - Health f .+ 222 1 Ca �el.back Road 1Vlarst+Dns ]Mills A = 047 '153 1 ; r COMMON-TV%+TE-ALTH OF NLA.SSACHUSETTS z(� EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS _k DFPARTMEI,TT OF.ENVIRONMENTAL'PROTECTION TITLE 5 OFFICIAL INSPECTION FORIN/I—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A �,�/� CERTIFI CATION Property_Address:" 91 �0�9 J r Owner's blame: Owner's Addre Date"of Inspection: a Name of Inspl rct plets prin2 Company Name: Mailing Address: . �-I . Telephone Number": . 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 the inspection.The inspection was performed based on my training and experience in the proper function and maintenance ofon:s"ite sewage disposal systems. I am a DEP -approved system inspector pursuant to Section 15.340 of Title S(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Sigb2ture: -- Date: :46 to L.1 •�'+W The system inspector shall_submit a copy of this inspection report to the Approving Authority(Board of"He'alth or DEP)within 30 days of completing this inspection.If the system is.a shared system or has a dt✓i'gn flow CLf-10,00,0 g'pd or;greater,the inspector and the system owner shall submit the report to the appropriate re-;zonal office-of thy' DEP.The original should be sent to the system owner and copies sent to the buyer, if applicabl and the,approviil".Q authority. W r°' Notes and Comments c,3 W ****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. Title.5 Inspection Form 6/15/2000 page I Page 2 of I 1 OFFICIAL INSPECTION FORINI FOR ASSESSMENTS NOT I,OR �V�OI�IIN�'�R�Y .ASSESSi'+�IENTS SUBSURFACE;SEWAGE'.DISPOSAL SYSTEM INSPECTION. TION FORiVI ' PART A. CERTIFICATION (continued) Property.Address:q;49i � Owner: Date of Inspection Summary: Check A,B,C,D or E/ALWAYS complete.all of Section D A. System Pas§es: I have not found any information whichµindcates that.any of the failure criteria described in 310 CMR 15303 or in 310 CNiR 15.304 exist.Any failure criteria.not evaluated are indicated be.low. Comments: B. System Conditionally Passes: One or more system components.as described in the"'Cop dit.i onal.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. The septic tank is metal ari&over 20 years old, or the septic tank(whether metal or no is structurally unsound, exhibits substantial infiltration or exfiltration or.tank failure is imminent:System willpass 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 leaking and if a Certificate of Compliance. indicating that the tank is less'than 20 years old is available. . ND-explain:- _ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructedpipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board-of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than:4 times a year due to broken or obsMicted pipe(s)..The system will. pass inspection if(with.approval of the.Board of Health): broken pipe(s) are replaced obstruction is removed ND explain: Paee 3 of 11 OFFICIAL INSPECTION FORM -.NOT FOR VOLUNTARY ASSESSMENTS SUBSTJR.FACE SEWAGE.DI.SPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:t 6 Owner: Date of: pectin C. nrther.l valuation 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 nhless Board of.Health determines in accordance with 310 CMR 15.303(1)(b) that the System is not functioning in a manner which will protect public health,safety and the environmeut. 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'saltmarsh 2. System will fail finless 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 environment: _ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of 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 l 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.ras 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 if the well water analysis;performed at a DEP cerfified.laboratory, for coliform bacteria and volatIe oreanic compounds indicates that the well is.free from pollution from that facilit;r 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: 3 Page 4 of. 11 OFFICIAL IieiSPECTION:FORM-NOT FOR VOLUNTARY ARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECT ION.FORM PART A CERTIFICATION(continued) Property Address: r 'Owner: Date of Ins ction: e� �/ i ,mbex _• Y` Joe) D.. System Failure t.riteria applicable to all systems:;. You must indicate"yes" or"no"to each.of the following for all inspections: Yes No ,7 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 Static liquid level in the distribution box alcove-outlet invert due to an overloaded or.clogged SAS or l cesspool, . Liquid depth in cesspool is'less.than.6" below invert or available volune is Iess than %day flow Required pumping more than 4 times in.the last year NOT due to clogged.or-obstructed pipe(s).Number of times pumped y� Any 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 tributary to.a.surface l water.supply. Any portion of a cesspool.orprivy is within a Zone l of a,public.well. _ V Any portion of a cesspool.or privy is within 50 feet of"a private water supply well. Any portion of a cesspool or•privyis:less than 1.00 feet but greate.r.than.50 feet:from a private water supply well.withno 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.facilityand the.:gresence.of ammonia nitrogen and nitrate nitrogen is equal.to or less than 5 ppm, provided that no other failure criteria are.triggered. A:co.pyof the analys8.must be attached to this form.] //0 (Yes/No)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 tile system must serve a,facility with a design ilo�v of 10,000 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 _ _ 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 Wellh ad 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 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 3.10 CIvIR 15.304.The system owner should contact.the appropriate regional office of the Department. Page 5 of I OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS , SUBSURFACE'SEWAO.E DISPOSAL SYSTElY1 INSPECTION FORtVI PART B CHECKLIST Property Address: Owner: r Date of Tn 'ction: / ��/ � Check if the following have been done.You must indicate`.des"or"no" as to each of the following: Yes. o Pumping.information was.provided by the owner, occupant, or Board of Health Were anv of the system components pumped out in the previous two weeks Has the system received normal flows in the previous two week period? ice— — _� Have large volumes of water been introduced to the system recently'or as pair of this inspection? Were as built plans of the system obtained and examined? (If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? ' J Was the'site inspected for signs of break out ? �— Were all system components, excludingthe SAS, located on site Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of thebafr'les 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: Yes o 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 CIVIR 15.302(3)(b)1 5 Page 6 of I I OF'FICIAi: INSPECTION;FORM•=NOT FOR VOLUNTARY ASSESSMENTS .SUBSURFACE ISEWAGE DISPOSAL SYSTEM INSPECTION FORM PAR-C SYSTEM It�IF.OPO4ATION Property Address:c�JI - � G* Owner:. Date,of Inr= ection• FLOW CONDITIONS RESI.DENTIAL Number of bedrooms.:(design): Number of bedrooms(actual).: DESIGN flow based on 310,CIv1R 15.203.(for example: 11.0 apd x#of bedrooms): w Number of current residents:. Does residence have a garbase grinder(yes or'zo): Is laundry on.a separate sewage system (yes or no): [if yes separate inspection required]. Laundry system inspected (yes:or no):4b Seasonal use: (yes or no): . Water meter readings; if available (last 2,years usage(gpd)): 0�. Sump.pump (yes or no): s, y A Last.date of occupancy: Uh oy COMMERCIAL/INDUSTRIAL�L, Type of establishment:, Design flow(based on 310 CNIR 15.203): gpd Basis of-design flow(seats/persons/sgft,etc.): Grease trap present(yes or no);— Industrial waste holding tank present(yes or no):— Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings; if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: � 211 � ` Was system pumped as part ofthe inspection(yes or n If yes,volume pumped: gallons --How was no pumped determined? Reason for pumping: TYP OF SYSTEM _Septic tank, distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _ Shared system (yes or no)(if yes, attach previous inspection records, if any) _Innovative/Alternative-technology.Attach a copy of the.current operation and maintenance contract(to be obtained from system'owner) _Tight tank _Attach a copy.of the.DEP approval -.Other(describe): pproximate age of all components, date installed (if known)and ource of in orma �n _ Were sewage odors.detected when arriving at the site(yes or no): /0 6 Page 7 of 17 OFFICIAL INSPE:CTIWNT FORM—NOT FOR 'VOLUNTARY ASSESSMENTS SUBSURF. ACE SEWAGE DISPOSAL SYSTEM INSPECTION-FORM PART C SYSTEM INFORMATION (continued) Property Address: ,^ 24� Own er• Date 61&ection BUILDING SEWER(locate on site plan) / (} Depth below grade: .Materials of construction:_cast iron _40 PVC_other(explain): Distance-from private water supply well or suction line: Comments(on condition of joints, venting, evidence of leakage, etc.): SEPTIC TANK: (locate on site plan) Depth below Grade:_ Material of construction: oncrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list aae:_ Is age confirmed by a Certificate of Compliance (yes or no): —(attach a copy of certificate) y� Dimensions: `) s Y 5 Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: 5,> . Scum thickness: r> Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom 9f outlet tee r b ffle: d ✓r " a How were dimensions determined; Comments (on pumping recommendations, iMet and outlet tee or baffle condition, structural integrity, liquid levels related t e o outlet invert, evi ce of leakage, etc.): at w o Ze GREASE TRAP./ ,Voocate on site plan) , Depth'below erade:_ 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 oflast.pumping: Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Page 8 of 1..1 O FICIAII INSPECTION FORM—.NOT FORYO.LUN'ARY ASSESSMENTS SUBSURFACE..SEWAGE DISPOSAL SYSTEDY1 INSPECTIO FORM PART C SYSTEM I1 tFORAIATION(continued). Property Address: Own er• r Date of In' ection�d__=� � '>^+ TIGHT or HOLDING TANK-A40 (tank must be pumped at time of inspection)(loc.ate on.site plan) Depth below grade: _ Material of construction: concrete metal: fiberglass polyethylene other(explain);. Dimensions:; Capacity: gallons Design Flow: gallons/day Alarm present.(yes or no):. Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments (condition of alarm and float switches, etc.): DISTRIBUTION BOX: (if present must.be'opened)(locate on site plan) a Depth of liquid level above outlet invert: 9 Comments (note if box is.level.and distr l,.any evidence of solids carryover; any evidence of . akage into or out , f box,et . of -/)A.' % 0 , PUMP CHAMBER/, (locate on site plan). Pumps in working order(yes or no): Alarms in working order(yes.or no): Comments (note condition of.pump chamber, condition of pumps and appurtenances; etc:.): Pabe 9 of l l OFFICIAL INSPECTION FORM. NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORM ATION(continued) Property Address: Cry' Owner: Date ofI ection. jPy s/ (� SOIL ABSORPTION SYSTEM (SAS): _(locate on site plan, excavation not required) If SAS not located explain why: Type ,- .leaching.pits,number: l -leaching chambers;number: leachine.galleiies, number: leaching trenches, number; length: leaching fields,-number. dimensions: , overflow cesspool,number: innovative/alternati-ve system- Type/name of technology: Comments (note condition of soil, signs ofhydraulic failure, level of ponding; damp soil, condition of vegetation, CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) ' Number and configuration: Depth—top of liquid to inlet invert: Depth`ofsolids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of.groundwater inflow(yes or no): . Comments (note e-ondition-of soil; signs of hydraulic failure, level of ponding, condition of vegetation, etc.'): PRIVY:.40 (locate on site plan) Materials of constriction: Dimensions: Depth of solids: Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):. 9 i Pace 10 of l l OFFICIAL INSPECTION FOIE NOT FOR VOLUNTARY AS.SESSMENT.S . SUBSURFACE SEWAGE DISP©SAL SYSTEM.INSPECTION F0RINT - PAIN-C SYSTEMJNFOPUNIATION(continued) n Property Address:' ek Owner`�� Date ofJ, ection:. SKETCH OF SEWAGE:DISPOSAL SYSTEM Provide a sketch of the sewage disposal.system including ties to at least two permanent reference landmarks or benchmarks. Locate all.wells within 1:00 feet:Locate.where public water supply enters the building.41 �-- io ?Js Icx Lefj�-d\ i l ` � � Page 11 of I l OFFICIAL N ISPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEMM. INFORMATION(continued) Property Address: Owner: � Date of I,ns, ection SIT1E EXAM Slope Surface water Check.cellar Shallow wells Estimated depth to around water °feet Please indicate (check)all. methods used to determine the high ground water elevation: Obtained from system design plans on record -If checked,date of design plan ieviewed: Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with.local excavators, installers-(attach documentation) Accessed USGS database-ezolain: You must describe how you established the high ground water elevation r / ✓3 35 ]1 Permit Number: Date: Completed by: ' HIGH GROUND-WATER LEVEL COMPUTATION Site Location: ��l �ala �c /'' j/�S Lot No. 1 � � Owner. � Address: �,� Contractor: C e Address: �7�Y x-s�.Y _..---- _........_..... STEP 1 Measure depth to water table ---- to nearest 1/10 ft. ....................... ........ .Date. ................................................ month/day/year STEP 2 Using Water;Level=Range Zone and Index..Well Map locate site and'determi'ne: .Ap.propriate.indexwell......................................��// © Water-level range zone ..................................................... STEP 3 . Using._. onthly report"Current Water Resources Conditions" determine current depth to water..level for index well ........................... month/year _:....;_._M,,... ,,..._...- -------------........ _. STEP 4 U'sing Table of Water-level Adjustments for index well (STEP 2A), current depth 'to water level for index well (STEP 3), and-water-level zone (STEP 28) determine water-level adjustment .......................................................................................... STEP 5 Estimate depth to high water by subtracting the water- level-adjustment (STEP 4) from measured depth to water level at site (STEP 1) .................. Figure 13.—Reproducible computation form. 15 L i °7 q y 90 - 7S' I/g�l a OF BARNSTABLE 4�� J�� 9��LOCATION LC 4� ��LWN 4M � Pt>• SEWAGE # ^ ^ VILLAGE � Pe,<;Z y , /Vt(LLB ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. ' 27(x SEPTIC TANK CAPACITY LEACHING FACILITY:(type)(p (size) C. NO. OF BEDROOMS PRIVATE WELL O PUBLIC WATER BUILDER OR OWNER ��(� ��C DATE PERMIT ISSUED: Z7 DATE COMPLIANCE ISSUED: - �� - VARIANCE GRANTED: Yes No L/ � (5�7 n1 C7 D"Alz—�Lu N C9nrt Ibbb rse L- �`f � T1RN K I 3 c ,D S�i12t iP uT7AN r�N� �x(o POEce�;F PIT- l�.i 2`aF 12��s�dN� f z� A - 0 Ton �3 No....................... FEB.......................... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ApplirFa#ion for Disposal Marks Tnnstrnrtiun Frrmit Application is hereby made for a Permit to Construct (Vor Repair ( ) an Individual Sewage Disposal System at: �'`�................__....__.GP=* ...�D............ ...................... ..... 1 ' ----......-----.......................... Locat' n-Addres _ or � :....�..�. t 'Owner •�,o -------------------------- - •• --- bT ..............i A ress :. P2MOV�}� MA� .ffkP,o- D.L$....... ----.•-----.---- .y -t�. -, -- ..................... Installer Address + Type of Building Size Lot-`&80 :�_.-..Sq. feet V Dwelling—No. of Bedrooms..........6................. .Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers — Cafeteria Q' Other res .................. ..... ------- Design per person per day. Total daily flow....... ..........._gads. ii WSeptic Tank—Liquid capacity .gallons Length_ --.(--.. Width,5.'®. .. Diameter................ Depth __.._.....-_ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area___.__ ........sq. ft. Seepage Pit No......I............. Diameter.._/.."._�....... Depth below Total leaching area...... .s t. Z Other Distribution box (✓f Dosing ank ( ) '-' Percolation Test Resul Performed by__ .____ __.__ �N� �i►/C• ��f7 . Test Pit No. 1.__. ....__.minutes per inch Depth of Test Pit..... Depth to ground water/1�QE....__. f%, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ODescription of Soil..4� 3-----l�P-- --�tJ�So/L••--•--------------------------------•-•-----•...-•---....--------------------.....-•---......---• U ..................................13..-_ �_._�Ti'A L ----------------------------------------•---------•-----------------------•--...-•---------......---•-•---•- w ------------------------------- - ......-------•---------•---------------...•••---------------------------------------•-•--•-----.......--•---------•-- VNature 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 iI'L 11 5 of the State Sanitary Code-The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee issued by the b of h h. __GG .. ��-•••--•--•• ................................ 2��Application Approved By............. ---••---•--- -------•---------------•-----••-•-•-•............------- Date Application Disapproved for the following reasons-----------------------------------•-------•-------------------•----•--•-------•................-••.....-------- ---••-•----•--•-•---•------...--•------------------•---..................-----------............----------••--•••------------••...-•----•-•••••-•-•---•-••----•••-•-•••-••---••••-----••••••---•--•----- ' I V Date PermitNo.............................................V..._........ Issued........................................................ Date No-Z :10(0 r F�$%—�_............ _ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Apptiration for Disposal Works Tonstratrtion "Trani# Application is hereby made for a Permit to Construct (`:/'j or Repair ( ) an Individual Sewage Disposal System at: ,• _ ................_........... '=: �% "C: ................................. .............................. 4- .............................................. jogLocation Address- ,r A or Lott'Naw ---•---•- ...... -�--------•---- ...........................................-------------------•-------•-- ..........--..............--�;;- -.... .--•w--- ter-------------........... Owner AddressIf E ' '...............•--^T j ` f• .. .. ! �~ . r ...... ............................................... Installer Address Type of Building Size Lot__I b��.` . ._..Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) '_l Other—Type T e of Building No. of ersons____________________________ Showers — � yP g --------•----•-•---•-------• P ( ) Cafeteria ( ) dOther fixtures ...................----------•-•--•----•---......•- -------------------•--•---------------•--•-•----.....-•-----••-•---------..._......._....------ W Design Flow_____________ ............................gallons per person per-day. Total daily flow______._.�?�'�.__.___________..._....__gallons. WSeptic Tank—Liquid"capac>ty �� _gallons Lengthtir__"_ _'f_. Width5.*..� _.__ Diameter________________ Depth'_ _ _.._. x Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No..................... Diameter......_._%_______. Depth below ....... Total leaching area_`=...:-:._.__.___St. Z Other Distribution box (✓') Dosing.;tank / Percolation Test Results Performed by €k!f G j\Zl" � �`=' ` !�'4 f ' Date_. `! ?.4 _ a ---- =--•-----• Test Pit No. 1....U.......minutes per inch Depth of Test Pit....�"_________.. Depth to ground waterf_,h=:.�''�s~_____... 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P+ •• ................ ..................................................................................................................... i O Description of Soil., ___-... / V..____.__�113`� e .�..»j Cslx ,��--•----•----... ---------------------------- =' ------..........------......-----------------------.....•---------------------•-------............•--...---•---•--_...._ U Nature of Repairs or Alterations—Answer when applicable_______________________________________________________________________________________________ ..•----•------•-----••-•-----•••---•-•---•--•--•-•----•----•-•---••--••-•-•.....••...............•--•••----------••.••--•.••------•-....-•------•••••••••••-----....._.._................---•-•--•...._. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been.issued by the board of health. !__..... ................................ ................... •....._._............__.... Application Approved By �R_��-� ._ Date Application Disapproved for the following reasons________________________________________________________________________________________________________________ --....-•.....................................•-------------.....-•-------•------.........--•-----•---------....__...._......_.._..------•--••---•-••••----•••••--••---....-------••••--•.....--••------- Date PermitNo.-. ................................................... IssuecL....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ... ! .'...............OF....:.... .....s ' 1r :=........................................ (Irrtifiratr of TnanpfiFanrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (. ) or Repaired ( ) by................................................................ Installer r at. - = ........................... ............"-=............----`......._......---------•--- has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as descFibbtd in the application for Disposal Works Construction Permit No��O____I_�<) C - - --- -•---•---. dated---._.�Q 2.zV --- -------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ,116 � ........... ..............................OF..... ............_.__..r.. ._.....`_............_...._.._.._:..._........_._.... � Nam- FEE....................... Disposal Works Tonstrndion Vprrmit Permission is hereby granted...... = ................................................................ to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at No - - r Street ;'-- as shown on the application for Disposal Works Construction Permit N�:F<- ------------- ...... .............. ?Q/ � Board of Health DATE.......... -- -•------.!!.•.."....."... FORM 125!�� HOBBS & WARREN. INC., PUBLISHERS t '' t f. - GENERA I., NO TE�5 / ,44 64,01ATONS SHOWN ARE 0,4J /T A NE A P H �. ,L/ M/N/M= C S U OF / F r-- 2 �, /f9 8 T. O (1) 41N4 ESS DTHERlN/SE SPEC/FIFO. 00 J. 4LL P/PE5 TOXNP /N THE SYSTEM SHAk,C, _ BE CAST IRON OR SCHEDULE 4p PVC. Q ( (DO 0 O"G 00 4. ALL S'EPT/C TANKS, O/STR/BUTTON BOXES, ® � O 0 O AND 4 EACHING P/r.5 S q.44 , BE RES/CNEP O FOR H-ZO l IHES4 CO,40/NGS dWJE/1/ T @ 0 ( 0 0 0 (D @ 0 �9 UNDER P,4VING. S. MOVE .4k , 4/NSUITAB�,E• itWCIFIABC. 0 ® 0 0 0 0) 00 i'�E , .r - BENEAT/� THE INVERT E1,El1AT1ONS O 0 0 0 ® Q oA' THE LEACAHG P, FOR A - STANCE OF x„ _I 20 2„ �. >O" �Z�� /. SAN17.4RY TEE 1' _'� i `� O DO O •� ANR BACKFI44, W/TH C4AY-FREE S,4/VD AND,GRAVEL q,411/N6 APERCOG.4T/ON TYPICAL PISTRIBI/TION BOX _ RATE. OF .2 MINUTES PEA' 11VCH oR LEM .=.: =. 6, THE r_n ► 1, BOARD OF HEAk rH al!/ST rJo � ►�:o�,�r� /voT ro sc,4�.E -� TYPI CAL ZV C1-/ING P/T NOTE: P1,97 ?IBUT/ON BOX ANl7;---,-,GAO,, NOT TO 60,91-E BE NOT/FfEQ WHEN THE SYSTEM/S NEAR 09SER04TION RM5 Re1Nr-DRCE-R SEPTIC TANK BY t COMP�GET/O/Y,4ND PR/O/ r09,4Cf,,c'14L/N6. SEPTIC' TANK PERCO�AT/t2N RATE = 4. .::1 r'i -:, _. Q T y 47144,! -) . ..G.�I,.. ` A1G1ER/CAN PRECAST OR E (/A.4,, T. UNLI66S OTHERWISE NOTED A�G4, SYST�E.�l NOTE TANh'S NOT TO SC,�,L E 10, OBSERVATION PIT T0' BE EXCAVATED • -' .CO�NP4/VE'NTS SHAD!„(, BE:/NSz,4,1,.,C,£O 'IN • • • • BdA�'G OF HEA,LTH RE/NFDRCED Tf/iROIJGHOtJ 4' BELOW PROPOSED BOTTOM OF PIT :ACCOIIFP4NCE WITY T/.T�,E Y OF Tf,�EST.�4TE ENGJNEER: A/gROW ENGINEERING INC. W/Tf/ ELECTRIC l'YE�,6�EC' `f'J�'E !�3'/TH .Za- %z' ELEVATION TO VERIFY SOIL. CONDITION �5,4N/TA/?Y' COOS ANO ANY .CJCA4. RU�C.ES E.�/BEPDEP STEER, eODS' %N TDPF BOTTOM. AND WATER TABLE. ENGINEER TO BE 0,47E = _ _y FL T I�VOOD PATH . yvHrc�H 444 r APP�,Y. CONCRETE IS LOCO f S./, TEST. NOTIFIED.PRIOR TO-CONSTRUCTION. -e NOT,E:'ACC,E55 MANNO,L,E'5 T'a SEPTIC TANK 103.00 .I f; ���:: A ND LEACHIN6 PITS TO B, 341I LT UP M LOT `/I t`/t EZEY, - 21+5 >z C3BLDW -1N1,5H 6",CDE. /2 F/N/SH GRA©E �s - 28359+ SF F/N/SN GIfAPe OXER TANK p 1% ®G�At XE FIN1514 G,2AD,E OVE,2. E,GEY- 16+0 ELEt!=14+0 .13+8 LEACH/NG P!T 13+0 2u4F /a %4yO . U _ ... u....,.. ,FAST N�' INV= 12+75 - a _ u ° oaa /N =12+ 24 Of 314 /IVV�12+50. G,4,�.. /ST. BtIX ® O fl •O m o0 0 2 0 CONC ETE O C f /2 LEACIiING .S° RE/NFORC�D E,( PIT < 4c STA,B,GE) � m �.v._ m O O 0 o O O 0 - SEPTIC TANK CD m ( /NV=I I+50 o BOTTOM OF P IT ,.p.. N - (To 8E kENE.G c STAB.C:E) 5+50 Box LOT 45 }�-----�° --.� (A 1,R SEPTIC 2'=0" - • IO 0 2 O TANK „ �6 6R �, ,C.,EAG H//V G P!T 20 (TO QE 4EYEL 4 .6TA134Z) _24 TYPICAL OeWAG,E 5V5TEM P,QOFI,C.� 2g R / 2s . NOT TOA.�.Er a , 28 eve 30 i - r SEC T/ON• PAh'CE,L, AGO T APPX6%5S w __ _� ' 12 Lu - o -- ON/NG•R S 7'RlCr, F�,DOD H.444RD. .ZONE o - ion 2a v siGN CRirER�,� �,��Ewv PROPOSED ZOUTION OF OI�Yf.CUNG 0. /4 LOT 43 - NLIM,�E'R 0r ,06J0A OMS ,EXIST.' CONTOUR B. --8 fPV SONS PER DE PAWAf �- PROPOSER. CONTOUR E sr� E .�_ , - S ! lu 22 GAA:I.ONS PER PE/RSbN PE!?DAY v E,�-ISr. SPOT Fk,6'YAT/Oly E.4CfI/NG RE l///t"ED ,: ,- • Ph'OPOSEO SPOT E,E,EVATION d f0 � _.,> :• ��A .. /6 /B 20 1 24 �.EACHING )cwov/hEh �� ,. RERC04AT/ON TEST l� NO PA5P,0 A.t, OBSERt/ATION P/T � - PSI T.4f' CAN ENGINEER , - • - , . t I _ 1 ..I�. , ARROI�Y E/Y�/NEE' /NG_l/I�C' . . j • SEWER PES/G/ y 4W S/DEiY.4C.,C, �, ,.. , 1 , r� r . _-< ( BO d - i Goa r f > S / D • _ SCALE� D SHEET= TO TAX. , JrAWN !?!� �Y• CfirECA'E©DYE APP B Y: PAGAN NO. • REV/SED. 9129187