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0006 DELL AVENUE - Health
��6p.DellSAyenue, " 047- 156 Marstons Mflls i i I I 5 No. Fee / BOARD OF HEALTH TOWN OiF BARNSTABLE Rppltcattou _for Yell Cou.5tructtou Permit Application is hereby made for a permit to Construct , Alter( ), or Repair( ) an individual well at: � IN,\ AIJ ,V".,� _ Lao-ane iS !- --1115( Location-Address r Assessors Map and Parcel KEY, �V ��� ;�\ O er Address �A O'tiz!;* -20 93 ►QrUM I ht 02153 Installer-Driller Address Type of Building Dwelling J Other-Type of Building No. of Persons Type of Well �11 -30AL,0 Nc-- Capacity cJl-q(Pl� Purpose of Well Agreement: The undersigned agrees to install the afore described individual well in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation-The undersigned further agrees not to place the well in operation until a Certificate of Compliance has been issued by the Board of Health. Signed w "- Date L( Application Approved B � �) I Date Application Disapproved for the following reasons: Date Permit No. -LL d Ds Issued Date -------------------------------------------------------------------------------------------------------- BOARD OF HEALTH TOWN OF BARNSTABLE Certificate of Compliance THIS IS TO CERTIFY,that the individual well Constructed( ), Altered( ), or Repaired( ) by Installer at has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. Dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORILY. Date Inspector No. �J �/ Fee 24 5 BOARD OF HEALTH TOWN O'FABARNSTABLE 01pprication jfor Yell Construction Permit Application is hereby made for a permit to Construct( Alter( ), or Repair( ) an individual well at: Location-Address Assessors Map and Parcel l ) 4 Owner Address nstaller-Driller J Address Type of Building Dwelling Other-Type of Building No. of Persons Type of Well �} SCh�KD ��� Capacity Purpose of Well 1' .c J Agreement: The undersigned agrees to install the afore described individual well in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation-The undersigned further agrees not to place the well in operation until a Certi cate of Compliance has been issued by the Board of Health. Signed _ � � �i _ _ Date r Application Approved B}�--�i T E Date Application Disapproved for the following reasons: j Date Permit No. \P ' c,411 G Issued c?)1 1 } Date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate of Compliance THIS IS TO CERTIFY,that the individual well Constructed( ), Altered( ), or Repaired( ) by Installer I at has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. Dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORILY. Date Inspector BOARD OF HEALTH TOWN OF BARNSTABLE '` lVerr ctCou5truction Permit No. tN���1 - Gc�� Fee Permission is hereby granted to~ �, Installer J to Construct(✓), Alter( ), or Repair( an individual well at: No. ft)i1\\ Street i as shown on the application for a Well Construction Permit No. ��_ ,►�( G - Dated C ! Date Approved By Assessing As-Built Cards Page 1 of 2 I' TOWN OF BAMSTABLE LOCAnON �/ Ayi SEWAGE#_2w( _ _ VRI AGE i v c 07 i 1!f —ASSESSOR'S MAP&PARCEL V7— /56 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY I OOd LEACHING FAaM(type) c_ 96d6s (size) 10orzeX 11 1 NO.OF BEDROOMS 3 OWNER 2trl A-A St1 i'(( d a of PmEw•r DATE: 30/7—J 1 COMPLIANCE DATE: Svaa m Dista=Bdwm the: MasimamAdjugedGrmmdwuwTablewthBan=ofLeachingFacility 304 Fcet Private Water Supply Wall and EmchiogFact7ity(lfmy wells==on site or within 200 fat of lewhiog facft) Feet Edge of Wadand and L4mdft Facility Qf`aazy�w,etlands exist within - n /�3oo feet ofleachin��( _ Few FURMSHED BY ��- i FrOAT 1 22' _ 16 .A 3 ; By V-Z'' A qq'Z M 46' As 5-r io, 1* `Jo.Q,. + b 0 t L btm://www.townofbarnstable.us/Assessing/HMdisnlay.asv?mapuar=04715b&seq=2 9/12/2014 W Al3LIS LOCATION 1649 e SEWAGE # tJ'" VILLAG Uti ! ASSESSOR'S MAP -a LarA7 N� 7'7 DU INSTALLER S NAME & PHONE NO. 100 t'�0 SEPTIC TANK CAPACITY ,�Ddd LEACHING FACILITY.Atype) / t NO. OF BEDROOMS PRIVATE WEL OR BLIC W BUILDER OR OWNER leo DATE PERMIT ISSUED.-.- DATE .COMPLIANCE ISSUED; V.ARIANCE.GRANTRI_t % No 407' ya Town of BAmstable. P# Department of Regulatory Services • Public Heath DivisionKAM Date sate. $ 200 Mai*StteeG H'�.annis MA 02601_ • � tbsy.his ' � �.... ff0 AMtJ. h U-� 'Time_______ Fee Pd: Date Scheduled -2, i ' `, $oil 5uitahili ,Assessrhent fir rSewage`Disposal � c�l f � ° \ Witnessed By: ' Performe d By:_ t LOCATION& GENERAL INFORMATION Location Address•.%_ � ownces Name (V Address Assessor's Map/P4r+cel: / Engineer's Name NEW CONSilt&ON REPAIR i Telephone# Land Use Slopes(%) ' Surface Stones Distances from: Open Water Body ft Possible Wee Area _ft Drinking Water Well ft Drainage Way ft. Property Line ft Other ft SKETCH:($treat name,dimensiods of lot,exact locations of test holes&pert tests,locate wetlands in proximity`to holes) i ; Parent material(geologic) Depth to Bedrock Depth to Groundwakdr: Standing Water in Hole:' Weeping from Pit Race Estimated Seasonal ilh9h Groundwater DtT- ERM NATION FOR SEASONAL HIGH WATER TA-tLF' Method Used: . ' in, Depth (bperved standing�in obs.hole: 1n. Depth to soil mottles: Depth toiweeping from side of obs.hole in, proundwatet Adjustment it Index Well#, Reading Date: Index Well levt l Act.faetOr,,,._.,.. Adj.Groundwater level I PERCOLATION TEST'• Date- x4n" Observation I I Time at 9" . ....__..— Hole# r i l , Time at 6" • Depth of Pere Start Pre-soak Time.@ _ Time(9"-6") -- ----.---- End Pre-soak —�--}- Rate MinJinch 1 /" 7 Site Suitability Assessment: Site Passed Site Failed; Additional Testing Needed(Y/N) Original:.Public 13e$1th Division Observation Hole Data To Be Completed on Back ***If percolali6n test is to be conducted within 100'of wetland,;you must first notify the Barnstable C44servation Division at least one(1)wedk prior to beginning. DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. onsis e c Gravel) — � El 1 S a i DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color ;�. Soil Other Surface(in.) (USDA) {Munsell) Mottling (Structure,Stones,Boulders. nsis enc %Gravel) Ai DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency, o Gravel •� ' V_ DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones.Boulders. Cnit Flood Insurance Rate Man: Above 500 year flood boundary No_ Yes Within 500 year boundary No✓ Yes Within 100 year flood boundary No Z Yes ' Death of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pery a s terial exist.in all areas observed throughout the area proposed for the soil absorption system? ' w. If not,what is the depth of na rally occurring per ious material? 'T 1 Certification I certify that on (date)I have passed the soil evaluator examination approved by the Department of Environ ental Protection and that the above analysis was perform d by me consistent with P the required training,expertis n ex erience described in 3.10 CMR 15.017 Date Signature Q:\SEPTICIPERCFORM.DOC TOWN OF BARNSTABLE � LOCATION ll% all SEWAGE# 2ol l Ia ;VILLAGE � �j ASSESSOR'S MAP&PARCEL -7 INSTALLER'S NAME&PHONE NO. BOU54-P- le( SEPTIC TANK CAPACITY 1006 LEACHING FACILITY.(type) L %d (65 (size) it NO.OF BEDROOMS OWNER J'iy/A-,,, StJ f +J ✓1 PERMIT DATE: ¢'/7 J COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility L3 Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) tAJ'Y? Feet Edge of Wetland and Leaching Facility(If any wetlands exist within n 300 feet of leachin facility) ht` Feet FURNISHED BY C ��— JA AI 2.6" A 3 8 3 459 ° B4 33`2 A q 4i'2 8646 ' 46 30 Arl iv y ii , No7—o1l— 062 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes ftpliLation for ]Disposal *patent ConstCurtion J)frm t Application for a Permit to Construct( ) Repair(!4 Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. &j b2/(A(/@ Owner's Name,Address,and Tel.No. .��„ s �� ,� sb a-„� sL,,,P ��� Assessor's Map/Parcel 6 6e L 'g7y-e- .2oc-6 y-c- 40 Z S- staller's Name,Addresss,s and Tel.No. Designer's Name,Address,and Tel.No. o"A/e /d.Ii4,1r-fd-y /3ok 649 S'�idwic� 0,4w ol4Tb.7 0ZS7o 3 t- Zo/6 t- SA,1014. /CA o d"f? 207 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3 Q _ gpd Design flow provided q �.cc� gpd k Plan Date �3 Z ^.1 Number of sheets Revision Date 016ti/-C— Title Size of Septic Tank 1.49" Type of S.A.S. S 76AJ-E Description of Soil dam' Q_ 021Ah-1 Nature of Repairs or Alterations(Answer when applicable)_ 1?e/b14c-e_ / i471.2f� h-vc-4 j0 Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board o Ith. Si d Date Application Approved by Date Application Disapprove y Date for the following reasons Permit No. 20l 1 — O 6 Z Date Issued -----------------:.�----, . ..�. ;....,-..-wrr�-..ntitrr�i...''VYyc�^•.SIrr•a-�-7Yt,.W^-.,t..+w���.,;w..w'�..».�.�-�.-...w-a�i.-�-••„y.-..__._...._....�-,..--�Yy....,.-.-..-,r+_,ti......_wr w.a-.-xr--•r-w..,-r..w__-�-••„c: .`�_..._,.r.. _„-. e No��I I- 0%2_ 4 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes applitatlon for ]Disposal 6pstem Construttion permit Application for a Permit to Construct( ) Repair()6 Upgrade( ) Abandon( ) ❑�'°Complete System M Individual Components 1.0. Location Address or Lot No. & D2l(A(le- Owner's Name,Address,and Tel.No. dh . S S 6+ i3iii4✓�'Se-/// v.4 -. Assessor's Map/Parcel t �� de l/ .4a_e S-0cF 6 S/.C- V92 5- Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. Rvc,5Fit /d J;""/a-'e Rai' Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building �i�I S�Q,l ei k/ No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3 0 gpd Design flow provided gpd X Plan Date 3` Z - Number of sheets Revision Date 46Aj-e— Title / Size of Septic Tank /DG� Type ofS'A.S. ,S 76.y Q��SS < J k' 'e Description of Soil See ��irf it Nature of Repairs or Alterations(Answer when applicable) Date last inspected: ' Agreement: t The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board oaf He. lth. Si .n d w w Date Application Approved by " rs Date Application Disapprove : y Date-- t for the following reasons ,t Permit No. �.D I - 0(0 2 Date Issued 3 1 THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS i Certificate of Coutptiante THIS IS TO CERTIFY that the On-site Sewage Disposal system Constructed( ) Repaired( �) Upgraded( ) Abandoned( )by P 1W -r4r7i4,,*trL f-P,v,C c 7^,, c- at Xale. MM has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.Z011-0 6 2 dated 3/ Installer &4G,S705 / s�Hi�,�?,, y Designer /DXK— #bedrooms Approved design flow A�0 gpd The issuance of this permit shall not be construed as a guarantee that the system will fun tion�as designed. Date a y Inspector - r - ----------------- No.GO 11 —062 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION BARNSTABLE,MASSACHUSETTS Misposal 6pste"onstrurtion J)ermit Permission is hereby granted to Construct( ) Repair(k) Upgrade( ) Abandon( ) System located at Al 15 and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:rChstruction must be completed within three years of the date of this permiittDate 4 /( A roved b L� ' PP Y Town of Barnstable y Regulatory Services Thomas F.Geiler,Director HARNW-A$LE, a Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office:.508-862-4644- -Fax: 508-790-6304 Installer &Designer Certification Form Date: �PGN � -7-0l Designer: �� � IM � �I Installer: � � Address: . Address: 0 0. was issued a permit to install a (date) (installer) septic system at tO T cu/ Me,T "IA�I Y' based on a design drawn by ^a (address) 10 �° A�0 dated Z d 11 (designer) l� ` certi that the septic stem referenced above was 'fy p y installed substazltlally according to Elie design, which may include minor approved-changes such as late x3al relocation of the distdbut on box and/or septic tank, . I certify that the septic system referenced above was ins+ailed W1 '; a3or_changes (%e, greater thm"l0' lateral relocation of the SAS or--any vertical.roiooafian of any component of the.sep-ff,system}but in accordance with State&L6cA Regulations. Plan revision or certified as-1; iyy designer to follow. r., '�ZM Q1:Mqs� (16talleitvs Signature) C WSW :m R`Q� P�. sq�►irAa�P� (D er s Signature} (Affix e gner',s Stamp Here) PLEASE RETURN TO I3ARIiISTAET�E PUBLIC DIVISION.,HEALTU.DIVkSI� C RTIFiC TE ®F.: COMPLIANCE WILL`=NOT : SSUED :UN ' BOTIi 7IRS•ifOR1V1 A,S_ BUILT CARD ARE RECE D B'Y f`BE:B. ; STABLE PUBLIC I; $I�1�T THANK YOU Q:Reai6sep c/DesignerCertification Forr, Town of Barnstable P#_ 30 S' Department of Regulatory Services Public Health Division;+toss '. . Date.: / l �At i6�g A,b� .200 Main Street,Hyannis MA 02601 Date Scheduled TimeFee Pd,. Soil Suitability Ass,essm`Mt ' S or ew f ge Disposal Performed By: ' Witnessed By; PC G,J/ -- LOCATION & GENERAL INFOR TION i Location Address s'� 4-1 511T Owner's Name S��� VC,^ p fAddress Assessor's Map/Parcel: Engineer's Name 64—vvi) /vM4SSoN NEW CONSTRUCTION t/ p " REPAIR. Telephone# Q33;,!02�7 , 1 Land Use 5ldpes(%) Surface Stones Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well ft Drainage Way ft Property Line —.ft Other ft SKETCH: (Street name,dimensions of lot,exact locations of test holes&per tests,locate wetlands in proximity to holes) Parent material(geologic) Depth to Bedrock Depth to Groundwater. Standing Water in Hole: Weeping Prom Pit Ppee Estimated Seasonal High Groundwater _ Method Used: DETERMINATION FOR SEASONAL HIGH WATER TABLE Depth Observed standing in obs.hole: in, Depth to Soil mottles: Depth to weeping from side of obs.hole: in. Index Well# In, ©roundwaterAdJtistment ft. Reading Date: Index Weli level Adj,factor— Adj,Groundwater Lcvel Observation PERCOLATION TEST bate Tirne l Hole# ` Time at 9" Depth of Pero L w,° ! Time at 6" Start Pre-soak Time @ tN, Time(0"-6") End Pre-soak i Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(YIN) 1 ` � E Original: Public Health prvtsioni t 4; .' Observation Hole-Data To Be.Completed`onBaek ------ ***If percolation test is to be conducted within 100' of wetland, you must first notify the Barnstable Conservation Division at least one (1) week prior to beginning. Q:8EPTIC\PERCFORM.DOC DEEP-OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Sdil Color Soil Surface(in.) (USDA) Other ) (Munsell) Mottling (Stricture,Stones;Boulders, Lp on i tenc % ravel DEEP OBSERVATION HOLE LOG SurfsDept from Hole# Soil Horizon Soil Texture Surface(in.) Soil Color Soil Other (USDA) (Munsell) Mottling (Structure,Stones,Boulders, C nsistenc % ravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Surface(in.) Soil Other `,.� (USDA) (Munsell) Mottling (Structure,Stones,Boulders. o gigtenc %Gravel ------------------ F, DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon. Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottlin g (Structure,Stones,Boulders. --Consistency.91 Flood Insurance Rate Man• Above 500 year flood boundary No Yes Within 500 year boundary No K Yes Within 100 year flood boundary No 7 Yes_ , Death of Naturally Occurrine Pervious Material Does at least four feet of naturally occurring pervi ujerial exist in all areas•observed throughout the area proposed for the soil absorption system? f �'�— If not, what is the depth of ha urally occurring pervious material? li 5. .nR t Certification I certify that on (date)I have passed the soil evaluator"exam nation approved by the , Department of.Enviro ental Protection and that the above analysis was performed by me consistent with the required training, ex r ' e n experience described in 310 CNM 15.0'17 Signatur ' Date !) f Q:VS BPTIC\PI;RCFO RM.DOC I i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Dis sal System Form - Not for Voluntary Assessments e'll -114ve— Tty Address l dRH .,5� 111(/q✓1 Owner Owner's Name information is / - /�J�//S g required for � /JnGt✓ Aj /_, A oad V-f every page. City/Town State Zip Code Date of Inspe lion 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: A. General Information When filling out forms the C( computer, r, use 1. Inspector: only the tab key to move your T4., cursor-do not Name of Inspector use the return E� key. 00 i ECW VQ Company Name Company Address City/Town State � Zip Code Telephone Number �J License Number t" B. Certification ca 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 c was performed based on my training and experience in the proper function and maintenance of on site cc cc: sewage disposal systems. I am a DEP 9 P y approved system inspector pursuant to Section 15.340 of ! Kr Title 5 (310 CMR 15.000). The system: °_ ? o •-f ❑ Passes ❑ Conditionally Passes Fails 3 d o ❑ Needs Further Evaluation by the Local Approving Authority /to InspejrSgnature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the 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. l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Dispose )ystem•Pag 1 of 17 c. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 6 Property Address Owner Owner's Name information is QrNf f�� vf� � required for every page. City/Town State Zip Code Dat tion B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/ always complete all of Section D A) System Passes: ❑ I 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 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. ❑ Y ❑ N ❑ ND (Explain below): 15ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Dispos IS t m Form - Not for Voluntary Assessments Property Address S(4 rvAk7 Owner Owner's Name � information is '�prys �� '' 4/ required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 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(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box 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 ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): I 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 manner which 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 15ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts JD Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address SC4 Owner Owner's Name information is A"Air 0�/(yam required for b ` a / every page. City/Town State Zip Code Date if Insp ction 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 environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and 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 if the well water analysis, performed at a DEP certified laboratory, for 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 o ❑ Backup of sewage into facility or system component due to overloaded or logged 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 above outlet invert due to an overloaded ❑ p�or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow 151ns•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Di spo al System Form -Not for Voluntary Assessments Property Address S64 ///P -A V7 Owner Owner's Name A-0 information is /� oy 1 I /V fi�0Y cPIf required for every page. City/Town State Zip Code DA of Ins ection 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: ❑ 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 water supply. ;1<❑ Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ y portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [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- 10,000gpd. ❑ 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 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 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. !Sins•09/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal ystem Form -Not for Voluntary Assessments ,gee- Property Address Owner Owner's Name information is required for every page. Cityfrown State Zip Code Da of In pection 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 ❑ []� Were any of the system components pumped out in the previous two weeks? ❑ Has 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 available note as N/A) ❑ Was the facility or dwelling inspected for signs of sewage back up? 2 ❑ 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: Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Dispos System Form -Not for Voluntary Assessments Pi Alle- Owner WProperty Address . `//wa Owner's Name information is 1#'aer�o�f L& O�6(�(! / ;l r0 required for every page. Citylrown State Zip Code Date if Inspelfction D. System Information Description: / /O� �� /�o� � etc `o,H /✓ 407 �-�- Number of current residents: Does residence have a garbage grinder? ❑ Yes No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes No Laundry system inspected? ❑ Yes No Seasonal use? ❑ Yes 4�3- l�o Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes No Last date of occupancy: C64�. Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 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: l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewa a Disposal System Form -Not for Voluntary Assessments Property Address SN Gl/vah i Owner Owner's Nam:IVA "AofA/V/s /"L �64,finformation is required for every page. City/Town State Zip Code Date Dfn2—specti6n 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 No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of Sy m: 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)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): 15ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposa Syste Form -/Not for Voluntary Assessments Property Address `SU l40?h Owner Owner's Name information is A/ai,5-4required for 6�$ (ak� �q every page. City/Town State Zip Code Date f Insp ction D. System Information (cbnt.) Approximate age of all components, date installe kn wn)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): Depth below grade: feetp)` Material of construction: ❑ cast iron ;4'0 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 o struction: 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: l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 i i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address /+ JC tit �l!✓or�I Owner Owner's Name information is /!`'/� Q��t'FlT g o2� required for every page. Cityfro`n n State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle '- J 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 / How were dimensions determined? ' - levIC.e— Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): PC4 N4 I n N o i74ed"'Od OC 4— Co., k' ald �e2s 10 Sood C''4104 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: Date t5ins•09r08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Seil Property Address /Xva Jkl Owner Owner's Name t� information is -�a,�j required for Allf UX o�T#v every page. City/Town State Zip Code Date of Ins ection 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 pumping: Date Comments (condition of alarm and float switches, etc.): Attach f r copy o current pumping contract (required). Is copy attached? ❑ Yes ❑ No 15ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 o1 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name /� /L information is !✓��CIYNf �� /V required for every page. Cityrrown State Zip Code Date f Inspection 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.): T 194 locj— AV So//C& o I-leG Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: 15ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Dispo/y(ssalll System Forrm -Not for Voluntary Assessments Property Address N 81V4Ih Owner Owners Name I information is �required for Alf— O� every page. Citylrown State Zip Code Date of Insp ction D. System Information (cont.) 6 X� Ty;/" e: leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ 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.): ON C f N ,n �v S0 ( C3 / J %,n P_t/ G b©t�C /2iS2•� IqrGa /tGt �ls 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 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Su l 1l ra Owner Owner's Name information is W�rA IH f A/`s AY ©-4(tvrequired for `S �t' every page. City/Town State Zip Code Datelof Inspefction D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): [Sins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address ,- >(4 Owner Owner's Name information is required for every page. Cityfrown State Zip Code D to of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where p 'c water supply enters the building. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately FaoviT R B 1 Asp' Or _ �117 15ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address / Owner Owner's Namel information is Name �'!'required for every page. Cityrrown 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: ❑ Obtained 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 wi ocal Board of Health - explain: Iq ❑ Checked with local excavators, installers -(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: C9 r4p r, r pis J% 4- �/041 /� • S is '4A10!i� /o w 01 /�Wvo�to_ Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 I Commonwealth of Massachusetts • Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments zv�4 Property Address u //11/a h Owner Owners Name J information is Alf// 0�6 Fe -2� �0 required for every page. Cityfrown State Zip Code Date f Inspection E. Report Completeness Checklist Inspection Summary: A, B, C, D, or E checked Inspection Summary D (System Failure Criteria Applicable to All Systems)completed tem Information— Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 I ' ��RAtLINl� i e�Q� 1 yry� SL l�RImL ZAw ar eet KrrG1iEN �THii w�aiL.lcru- � s� O N H . GP' 1�cICK t lwlt4, ROOM — —O 9grlrole.srr� 9L oo 4 1 K2y1 wwc�+u/�4><x} - f-L.WR VIAN . .. -- wsuc DOT VA49ptEHr-�R 'wv� � 1 a 1 tft ?LLAN 17 ofri o� TOWN F B R STABLE yll LOCATION O1 oC �� SEWAGE # �! VIIUAG 1 Uti�jL/4— ASSESSOR'S MAP LO INSTALLER'S NAME & PHONE NO. �(J 77 7 SEPTIC TANK CAPACITY /000 LEACHING FACILITY:(type)0f (s! d d o NO. OF BEDROOMS PRIVATE WEL OR BLIC W BUILDER OR OWNER �_ O �e�� �� DATE PERMIT ISSUED: ! 7?ol'�&,) DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No Zo7' ya Or/v sOPN No -�.®-------� Fss.....I.1 D.. .... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ...........1.0"ot..................OF.....40Ar!VA.4/r.......................................................... . 0.� Appliration for Dioposal Works Tonstrnrtion ami# Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at: ................��... ....................E .t f.��P�'�....-...ymk -.............. -4�.....1y.r�!r�!r��. .... .........-........._. Location-Address or Lot No. S ,a tx:►�c erg C.o Q -------------------- ................. ...,f,� Owner Address ........................................911�. --••-•--•--•-- ......... P9fS' /lsF..-•................................................... Installer Address Type of Building Size Lot...... Z�Sl.O....Sq. feet V Dwelling No. of Bedrooms___Tl x�,r.......................Ex Expansion Attic a g— p ( o) Garbage Grinder e) ok Other—Type of Building ............................ No, of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures ............................ W Design Flow..................................05._gallons per person per day. Total daily flow..............................3�....gallon. if WSeptic Tank—Liquid capacity.1bf!.gallons Length.!R...6..... Width 4 _10--- Diameter-_-_.___. Depth...erl.-g.... x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No...... rtp.------ Diameter-----IZ!........ Depth below inlet._....4..._._.._.. Total leaching area...Z(04....sq. ft. Z Other Distribution box (x) Dosing tank ( ) aPercolation Test Results Performed by._C_._Fj.o1cJ.. Atxy-..E1At �i-.Ntjarr.... Date.... /z4/A7,,______________ a Test Pit No. I.....,�.......minutes per inch Depth of Test Pit....1Z........... Depth to ground water..... (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water OF _. aT----------------------------- ........................................................................................ O Description of Soil........ yam- -o .. s.,AbSc�A...................•--•--------------------------..._...........---- g x --•-------•--------------•---- ...Y�-_LLB 1'11.5.aQtarx! _Sx .w S.Ir�4Q.-•--------•----•----...-•-•-----------------•-------•------ PoLLYN.. � WIL50N � •------•----------------•--•---------------------------------•---•---•------------•----•--------........-----•-------•--....----....--------•---•---•-----••-----•------ •.........N-:30�7 116� U Nature of Repairs or Alterations—Answer when applicable................................................................. . -•------••--••-------•-•--•-••-------••••--••-.•------••-•....••••---•••-•-••-•----•...........................•-----••--••-•--•••-•-•-•••-•••------••----•-•-•----------•-- Agreement: /fo The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificat f Compliance has been issued by the boar health. Signed ... .. .. '..- ' to--l- .. -... 143� f..o------------ A lication Approved B .. Oa3a . PP PP Y ....... ................... .... .................. ... e � Application Disapproved for the following reasons: ....... ......................................... .................. .... . ........ . .............................. --------------------- --------------------------- ----------------------------------------------------I............... -- .............---......--..... /�rpy /y� ...............------------------ace----- ..................................------ V r �/I/ Dace Permit No. Issued ............ �.. i Fizz THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH /arr+�-► OF...... .��ar...... -------------------------------•--._................_.. pplirFation for Disposal Works Tnnstrnrtilan Prrmit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at: ................_.................................................................-. 4 Z ..... •....................................._._----•• Location Address or Lot No. CD---------------------------- -------- .......................................................... Owner Address ---•--•••••••••---••----••-•---------•-----•-- Installer Address Type of Building "� Size Lot.....L Zy ....Sq. feet Dwelling—No. of Bedrooms.._.Th.r.a_C•........................Expansion Attic (No) Garbage Grinder (�✓o) Other—Type T e of Building _______________ No. of ersons............................ Showers — Cafeteria a YP g ------------- P ( ) ( ) � a Other fixtures.......................... -••-•--- Design Flow...................................?..gallons per person per day. Total daily flow.._..._..___..._..............ZZ .._gallons. W � 1, a ii � i� WSeptic Tank—Liquid capacity.l.QOO.gallons Length_$'.�..... Width.41Q_ Diameter...... Depth.�-?9.... W Disposal Trench—No. .................... Width............T-__.... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No......Uti.e....... Diameter......t_2.......... Depth below inlet.....4-1.......... Total leaching area...26.4'....sq. ft. Z Other Distribution box (x) Dosing tank ( ) aPercolation Test Results Performed by..C,.f•"cs!_J_...L��IC__ ld^s�L s�� __W4 3►t_c.C_._. Date.... L�,�yQ_-..-.•_•-.•.._.- Test Pit No. 1...._P........minutes per inch Depth of Test Pit....l.Z........... Depth to ground water........................ Test Pit No. 2................minutes per inch ]depth of Test Pit.................... Depth to ground water.. a' ----....r------------------------------------.........................................................,......................... 1l.OF. O Description of Soil xVW Y; I �- )? ►il ��yrr 5�s • �..c, YN -- �►rA--gTEPH-•- LAL.. 0......................... . WtLj UNature of Repairs or Alterations—Answer when applicable.............................................................. .... „..N ,302M .e� tuft. Agreement: !' The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in ac the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed -------•------ .fir..... L 4 e ... js2s 9(I.-... ApplicationApproved BY ------------ -- --- '. --...... .. .. .................---------------.................................... 3iP ... Date Application Disapproved for the following reasons: ----------------------------------------------------------------------------- ----------------------------- ---------------------- --------------------------------------------------------------------------- - -- -------------------------------------------- ---- -•------------....... --........----...................... -------------------------------------- Da Permit No. -- ��-^ f 7 ................................... Issued ..........------------- ...............................[e....-- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ................. &. . .•}�-....... OF ---- -/a --------------------------------------- CneztifiratP d 010niplittne THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( .11�or Repaired ( ) by................ a�`..Y.. ------- fA,.-e...;,.. -----;;-i..X...............W' -----------------...................................... j- Installer at ------ ----------------------------------------------------------------------------------------------...................................----------------------------------------- -------------------------------- -------------- has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as descr' ed in the application for Disposal Works Construction Permit No. ...... .."'.Y. -V ............. dated ------ ���. ... �. .... �..... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT B CONSTRUED AS A GUARAAt'TE NAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE----------- -- -- -- ---------------------------------------------- ------------------- Inspector -----.......--------- ......-----------------•-----------.... .---------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH � , C� �/ ..............73-�- No .......OF...... „? :''�— `�'............................ .� .• l FEE... ......... Disposal Works Tnnirnr#i!an anti# Permissionis ereby granted.............................................................................................................................................. to Construct ( ) or Repair ( ) an Individual Sewage Disposal System atNo.......... `. --� j, ----.; ,. .--..--•------------------------•-••-------•------.-----.--..------•-----------------..------.------ Street as shown on the application for Disposal Works Construction Permit Dated.......Ay.- . ,/.Ql�._------ ....................................... ... .ems.._- -- -•-------•------ �%�_.-- o6YH�• e DATE ??--�34 ...-•------------------• FORM 1255 HOOBBS & WARREN, INC., PUBLISHERS I. I I y I I1 I !T I_ I 1. I. ! TILEt i HALFWALL �iInI'I . '; ...,-IiiI.:'',:.... .� ��• � N_� IiI �-----!Lo--O-R N-ALF-W I,I ----- ----.-.-�I I--I - .. .. G RILL NOOK - STEP - - -_ 6%10FlRBEAMDINING ROOM DECK. 60 FIR BEAM 10'X16'/ VELUX ------------- ------------------ VS 300 ------------ aaasa. o-••h- oh.•,es �iiI � �yA -•I '.�//iIr_�:��� ---. i-cQ.�o-II!,iII�-IIIi ' -- tv T ..■' if o OUTDOOR cc 14 QzC�JQZ�taLQ'�L r :d L2T ..] -]. 0 3. cGJQQ .� {� . ',. - .0 dm>O SHOWER W (20 X 6 C.O. 0 U) Lo QC — pO_Q o_ ILEXISTING HOME 10'-O` � W 0 cc 3"CONCRETE SLAB a 5 GARAGE. ------------------ -- Z cn ,0°bDNCRETE FILLED 9 CRAWL SPACE SONOTUBE4'-O"BELOW GFADE > 3/4'AGGREGATE O 6 MIL vAOR BARRIER W cr- Ma-0-CONCRETE WALL O Q BELOW GRADE W120•X10' F. W uj Ld CONT. C.FOOTING Ji a cU.---- ----- --- ---- ---------- ----------- -------------=PROPOSEOFLOOR LAYOUT .. T/ON SCALE TING 'DATE . DHAWNDv SPS/PAB VELUX VS PREVISIONS: k FONOATIONPLAN DRAWING NUMBEL",,�A F 0 2 - _ fir i j, i I ® ® CU ® ® _ CU-U z I', FRONT ELEVATION NOTE:ALL EXTERIOR TRIM.SIDING,ROO SNINGLES, LL GENERAL NOTES: &DETAILS TO MATCH EXSITING HOME. V A. 1. Before final Drawings and Specifications are issued for la � construction,they shall be submitted all governing building ® Z CZ'3�n agencies to insure their compliance with all applicable local and ' national codes. If code discrepancies in Drawings and/or /'\ W J IM W Cl) discrSpecepancies appear,the Designer shall in notified of such Q Z) O U discrepancies in writing by Builder or building official,and allowed to alter Drawings and Specifications so as to comply /1 4 Z m U o with governing codes before construction begins. LL 00 2. Upon written receipt of approval from the governing official, O d O to approved final Drawings and Specifications shall be submitted _n W «S Z U a a � / to the Builder by the Designer. Q 3. If code discrepancies are discovered during the construction - process,Designer shall be notified and allowed ample time to Li said discrepancies. 4. All work performed shall comply with all applicable local,state and national building codes,ordinances and regulations,and all other authorities having jurisdiction. Following is a partial list of applicable codes in force: a. Massachusetts State Building Code,780CMR,6th edition, 3/1/98 B. All contractors,subcontractors,suppliers,and fabricators,shall be responsible for the content of Drawings and Specifications and for -the supply and design of appropriate materials and work - . performance. C. All manufactured articles,materials and equipment shall be applied, installed,erected,used,cleaned and conditioned in strict accordance with manufacturers recommendations. D. Ail alternates are at the option of the Builder and shall be at the Builder's request,constructed in addition to or in lieu of the RIGHT ELEVATION typical construction,as indicated on Drawings. In Z O O Z w fn w o z w 0 J QFn W —3 0 c LU z 0 > Q 0 F71 FM cD 2 SCALE 1/4"=1'-0' DATE 09/23/02 DRAWN BY SPB/PAB REVISIONS: DRAWING NUMBER REAR ELEVATION Al I P 14'0" 12 A ASPHALT ROOF SHINGLES -- 6'-0 Uz'PLYVOOD cox � - -'--- --"- --"'- - - -.-_--- ' I I 2%ft OR 2%10 RAFTER --------- -------- _ 8°XS'CONCRETE i I = ROOF FRAMING V/ALL W120'Xl 0• GRIP EDGE � M � CON7'.CONC.FOOTING ! •> � I/J]�►'_ R30 INSULATION REMOVE _\ / i i pp EXISTING �--ALUM.GUTTER i j/• WINDOW _--� j 1X8 FASCIA PINE ^r ACCESSTO I ,y "SOFFIT VENT CRAWL SPACE' a IBEDROOM j - iX850FFITPINE 2-1' I •`- j 2X6 NAILER W •'I _-_ 2-2X4 TOP PLATE i-__ 2X4 WALL W/1/2"OSB 8131NSULATION I WALL SHEATHING \" I w , I I 1 f..-.._.-- - -- ---- - - - cn CRAWL SPACE a, 2^6" * * o Q N I NEW FOUNDATION "--'-'-'-" _ a—SIDING m ! I ________ N I R19 INSULATION I 2°CONCRETE \^\ NEW WALLS=® DUST COVER EXISTING FOUNDATION=� \ ! %4 BOTTOM PLATE z .,,,NEW XISTING WALLS=O 2Xt0.JOISTS ~ •e 2X6 P.T.PLATES W/SILL SEAL >, 8 5 .__..I ._._.._. .._..._-_ - W ' ------ - j 6/e"X 18"GALV.ANCHOR z t Iy m III BOLTS @ 6'-0"O.G. I � I T z I j I I � V m Z V BEDROOM j GRADE Q 8°X6'CONCRETE _ WALL W/20'%IO" I ' I I CONT.GONG.FOOTING I z z _ Lo a ' Lo Ld REMOVE I V ___________________ _________ EXISTING i •° I ~ 8"POURED CONCRETE '-------- J Cl WINDOW I to FOUNDATION WALL _ >p i O Z) X U) M o "'IEEE 2X4 KEYWAY o o - o o - __.____..._ J Z m Q o e co I h O co 4o Ln x4 z a n- k, 14"0" i Q ui — NC.FOOTING 20'Xla' yy FOUNDATION PLAN FIRST FLOOR PROPOSED TYPICAL SECTION PROPOSED 2X8 RAFTERS/CLG.JOISTS @ 16"O.C. NTS - --- ------------ r--------------------- - --- - - - - - - - - -- - - - - 12 2X6 COLLAR TIE — O a �r 2X8 CLG.JOISTS O W (7 i w¢ O LL u~3 BEDROOM BEDROOM z O�CCJLn O cc/) / 2X OXW U)W W J 1—QONQ Q8"XSA"CONCRETE WALLW/20"X10" -0"CONT.GONG.FOOTING 2"DUST COVER /23/02PB/ Z --------------- I ' DRAWING NUMBER j FIRST FLOOR FRAME ROOF FRAME A2 7 AssEssoRs MAP : NOTES:1 TEST HOLE LOGS � PARCEL : ---� (15(2 -- ,p., FLOOD ZONE: ��� 1�P�1C, I � . SOIL EVALUATOR:1�1 {/ 1) The installation shall comply with Title V and Town of t,;; jiBoard of -- WITNESS : ( 1 Health Regulations. 04 REFERENCE.j� 0(L*-jC {I' 1, 1.1Z DATE: V \ \ 2) The installer shall verify the location of utilities, sewer inverts and septic G r� . - components prior to installation and settingbase elevations. dO\/, Ze71 ICI PERCOLATION RATE:` z tW 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8" per foot. The first JV 0Nw two feet out of the d-box to the leaching shall be level. TH- I TH-2 4) This plan is not to be utilized for property line determination nor any other 0 purpose other than the proposed system installation. � 1 ►2 Z A l 4- Vo 5) All septic components must meet Title V specifications. � 6) Parking shall not be constructed over H10 septic components. \\ 1�� \ 7) The property is bounded by property corners and property lines. L � �46 �l f`a Z� 8) The property owner shall review design considerations to approve of total LOCATION MAP + �� 31 design flow and number of bedrooms to be considered for design. Receipt /� , � L✓1�1,� of payment for the plan and installation based on the plan shall be deemed japproval of the design flow by the owner. 9) The existing leaching or cesspools shall be pumped and filled with material -' per Title V abandonment procedures. Those within the proposed SAS shall l 1D be removed along with contaminated soil and replaced with clean sand per ' ND a7,W 1�J1, �C> Title V specs. \� 10)System components to be 10 feet from water line. Sewer lines crossing the --- - water line shall be sleeved with 4 inch SCH 40 PVC with ends grouted if applicable. The proposed SAS is being installed below the water service SEPTIC SYSTEM DESIGN line. The line is to be sleeved as aforementioned and maintained in place.I 11 garbage rinder exists it is to) If a g g g be removed and is the responsibility of the owner to ensure such. FLOW ES i I MATE 12)The installer is to take caution in excavation around the has line if such I I exists. BEDROOMS AT 10 GAL/DAY/BEDROOM - ,�OGAL/DAY 13)The installer shall verify the location, quantity and elevation of the sewer lines exiting the dwelling prior to the installation. j SEPTIC TANK _ ? GAL/DAY x 2 DAYS - GAL USE 100,) GALLON 'SEPTIC TANK ��Cl qLr I � SOIL AB40RPTION SYSTEM _ �H'OF Mgssq ID rn 0 �� E 2e ,, ► r .. SqN C SYSTEM SECTION 1.J� �'" �✓ice- �-- I Vc f i — r —, GAL SEPT I C TAN - l�iu11�`� - i, k Zj Ot i �l/ l / � ���Z rl�rC....f_— �. �.1^-''�L r�'�;�kl �f� < �;2J 10 0o C i 6 to S I T E AND SEWAGE PLAN zf LOCAT I ON : o PREPARED FOR : �/� SCALE: %Z ow DAV I D B . MASON ' DATE : DBC ENVIRONMENTAL DESIGNS EAST SANDWICH MA W DATE HEALTH AGENT ( 508 ) 833- 2177 1" r i S INDICATED ON PLAN 20 MINIMUM OR A DI NOTES: G 10 MIN. r / CO0 M ,E. 1. ALL WORKMANSHIP AND MATERIALS SHALL NF R T 0 D 0.E. /�` $ a I LOCUS TTLE 2, r s RULES AND TITLE 'S THE TOWN OF �g��.��_ � G MASONRY EXTENSION TO 12 POND BELOW GRADE<8EL _ 9ACICFILL WITH W C DISPOSAL 01= SEWAGE; TOP of FouHDAnoN 8� �.' _CLEAN . REGULATIONS FOR THE `SUBSURFACE D S , a e MIN 8G MASONRY EXTE N510N TO 12 AND `THE REQUIREMENTS OF`THIS PLAN. ¢ O Q DELL AVE BELOW GRADE LAN ! E TO 2. . ALL .COVERS TO SANITARY ..UNITS SHALL BE BROUGHT {� - Z �� GRADE. . _ Wi1}-IIN 12 ;OF .FINISHED. G ADE P 4 SCH 40 PV C PIPE V T AD 0 BRING COVERS 0 GRADE 3. ALL MASONRY UNITS USED T G S "."!5 PER N _ ;4 h FT AL BEMORTARED ,IN PLACE. FLI. SH L1 2 LAYER4 w uNE Fto..PER kr BLON 7 OF > H 'SANITARY 'SYSTEM SHALL BE GAPA E 4. ALL COMP ENS T E10 TEE W N 1bdASHED STO ER "U DER OR MYsnc e , OF WITHSTANDING H 10 LOADING UNLESS .:THEY A E Nr IN. 2Ti< LAKE M 2 0 GALLONIVES, RING AREAS H 20 LOA bING'i WITHIN 10 `FT. OF DR OR PA K . LEACH LEVEL _ OF RI R PIT U DER OR HIN 10 D VES 08 52. SHALL BE USED N W1T FTI 4 1tMIN. 3 2 R N .PA KI G WASH- STONE r u D 4 WASHED LIQUID F DISTRIBUT ION _ LEVEL 8b W TO COMPLIANCE WITH DEED I -BOX 5. NO DETERMINATION HAS BEEN MADE-AS C PL SHALL r RESTRICTIONS OR ZONING REGULATION`5. OWNER/APPLICANT I A ORITY. ♦o OBTAIN SUCH DETERMINATION FROM THE _APPROPRIATE UTH LOCAT[ON `MAP p q. . .GALLON SEPTIC TANK , , E LEVY, ELDREDGE 6 HORIZONTAL AND VERTICAL CONTROL, S E L z H N AL VE l 3 /S ASSESSORS MAP ' � 4 L .l _���__.__ PARCEL WAGNER, F L 0 BOOK I _ & FIELD NOTEBOOK # L /2 W w LIME ou BELOW FLOW uculo DEPTH`�'sEpnc TANK DEPTH OF nEr TEE BOTTOM OF TEST HOLE T 7Z.1 4 FEET 14INCHES 0. - , W OR, SGS PROBABLE`HIGH WA -LEVEL S FEET 19 INCHES u 6 FEET 24'INCHES IONS CURRENT ZONING INTERPRETATION: DESIGN CALCULAT W DISPOSAL SYSTEM PROFILE SEWAGE N._ FRONT SETBACK 3© MI FEET ' NUMBER OF .BEDROOMS NOT TO SCALE A UNIT' ; r- GARBAGE DISPOSAL MIN. SIDE `SETBACK 15 FEET ESTIMATED FLOW a TOTAL T 3 MIN. REAR SETBACK � T � GAL. DAY • _ �_ FEE ( ►►:© GAL../BR.fDAY X BR / 4G.5 A REQUIRED SEPTIC 'TANK -CAPACITY GAL. Q 0o A t OF 'SEPTIC TANK i , c� GAL SIZE A REQUIREMENTS LEACHING AREA 7 _._ PERCOLATION SOIL TE ST � s36 _ -" ,D 1 '2, 'S.F:_ BOTTOM AREA GPD. S.F =: SIDEWALL AREA_�GP,D./ a � ; _ DATE OF SOIL.- TEST r bf L.� w 2& g cr W /2 2 9 SF x�.5 GPD SF, .�7 7 GAL DAY . .< �--; SIDE ALL 2 Tr( � ��,.� � � V ? Lit ktf !mac%� Lk �* -�. .,..�- . , ,:. TEST ,B Y art k. _. ... ♦Z /.a F = GAL bAY � -. _f,< ., •. .. � ?-�--� BOTTOM 'T� /2 SF X GPD/S !l3 / WITNESSED BY NE ED s � r_ r G J .... ..:......c 8.rtea � C:c./ N NCH PERCOLATION RATE MI 1 F _ .GAL/DAY _80 of 4 BREAKOUT CALCULATION: TEST P I T 2 TEST PIT 1 ES • v w_ n so ELE ��, ELE .� ; _ j... x l J 0 �•q Bos}, .00 _ o .� a o t �. .,. ( � P � . r" t c,lm BM LF come � _ PIz o . {� � I rd 1 r LEGEND. .. ., _ Stone >, b / k r...c _ r l ELEVATION� EXISTING :SPOT ELE . _ o EXISTING ,CONTOUR_ .- - _ C r T NAI no TION 0 FINAL SPO ELE a .. N CONTOUR FINAL LOT 42" N T PIT 'LO LOCATION 510 s .'_ft. SOIL TES I . _. eorTaM of TEST HOLE 'BOTTOM OF HOLE ...3 . . � TOWN WATER c OR `WATER ELEV.. 1 As ph. berm _ P a u.r_r � TANK _ SEPTIC TA C� .. z ..,..�... -..3,.,_ / - ox a Dt RCBUTION B ST ` RY LEACHING P O \ \ / N PRIMARY W LEVEL ADJUSTMENT. ,�' ATER LE L LOAM r ,. �. .✓. LEACHING :..:PIT ,., ss RESERVE L H ., ., ;..PILE ,. T EMO to 0 BE R o. E . .,. ._ � WATER LEVEL >,. . A ATE, TEST D l h h L INDEX _WE L 6' \ - RANGE ZONE ° 5AVJ WATER LEVEL RA E INITIAL ISSUE E � . ,.. . � 1 DESCRIPTION BY ,._ � � WATER LEVEL FOR INDEX WELL N0. ATE:. D �., � o DEPTH TO ATE LE L D c� x � ,. Lot hU r FOR ;MONTH OF. nr. ESIGN . .t . . }.. SITE PLAN & "SEPTIC. D WATER LEVEL ADJUSTMENT A R. . AVE. _ . _.. . 42 DELL 3c.,..k..,., - .. ..� _ DEPTH TO `HIGH` WATER ., r .. IN ,. SS CHUSET S . � BARNSTAB�tE MA A 90 FOR $8 OF c V 0 CO. THEO CONSTRUCTION ` . N HEALTH S TEP HE APPROVED. BOARD OF HE '. LYN _ AL a+ s ON ILS n � 1 , 40 41 124 s 1 N 0. 12 No. SCALE. JOB. r Gt✓ Cs/ rc ST � _ MATE A ENT. iC \ SITS _PLAN.:.. SOCIATES INC. t 0 LEVY ,ELDREDGE & WAGNER AS 3 0 t�scel� aRc�r�crrs Paxx�s .loam. SURVEY RS 01 �M T , A 026 32 _ NTERVILLE M . 889 WEST MAIN STREET' CE r PP , N F PR RAPH 3 SUPPLY CO_' NEW fNGLANQ E OG C 8$ C 20> MINIMUM OR AS INDICATED ON PLAN _ NOTES: 10 MIN. / r 1: . ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO D.E.Q.E ' 0 LOCUS �. s ! RULES AND c�' LIl'RF MASONRY EXTENSION 70 12 TITLE 5 , THE TOWN OF ��rL 7s�'i-�2�.- .�_. POND BELOW GRADE SACIMLL WITH gS,o REGULATIONS FOR THE SUBSURFACE DISPOSAL' OF SEWAGE; TOP of FOUNDATION 8• MIN. fj'G.U 8�}.0 CLEAN MASONRY GRADE EXTENSION TO 12` AND THE REQUIREMENTS OF THIS PLAN. - DELL AVE LANE ' �- 2. ALL COVERS .TO SANITARY UNITS SHALL BE BROUGHT TO ={t�}r WITHIN 12". OF FINISHED GRADE. 4" SCH. 40 PVC PIPE _r 3. ALL MASONRY UNITS USED TO BRING COVERS TO GRADE Fs MIN. PITCH 1/8 PER FT. I 2•.LAYER of SHALL BE MORTARED IN PLACE: 4 PER Ftow LINE - I/a• - 1�2" 4. ALL COMPONENTS OF. THE SANITARY SYSTEM SHALL BE CAPABLE 5` 10" T� boa WASHED TONE OF WITHSTANDING H-10 LOADING UNLESS THEY ARE UNDER OR �'� MYSTIC 8q.7 3" MIN. rii< 2'-0" GALLON LAKE 2" MIN: LEACH WITHIN 10 FT. OFDRIVES OR PARKING AREAS. H-20 LOADING P 4'-°• 2 PIT SHALL BE USED UNDER OR WITHIN 10 FT. OF DRIVES OR 89'-� MM. 8 2.5 1 3/4 - i 1/2 LIQUID gO�) 4 WASHED STONE PARKING. LEVEL DISTRIBUTION 5. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH DEED Box -� RESTRICTIONS OR ZONING REGULATIONS. OWNER/APPLICANT SHALL OBTAIN SUCH DETERMINATON FROM THE APPROPRIATE AUTHORITY. LOCATION MAP /oot� GALLON SEPTIC TANK , z 6. HORIZONTAL AND VERTICAL CONTROL, SEE LEVY, ELDREDGE ASSESSORS MAP -7 PARCEL 454 & WAGNER FIELD NOTEBOOK LIQUID DEPTH IN SEPTIC TANK DEPTH OF OUTLET TEE BELOW FLOW UK BOTTOM OF TEST HOLE _ 79j, 4 FEET 14`INCHES OR USGS PROBABLE HIGH WATER LEVEL 5 FEET 19 INCHES 6 FEET `24 INCHES CURRENT ZONING INTERPRETATION: DESIGN CALCULATIONS SEWAGE DISPOSAL SYSTEM PROFILE MIN. FRONT SETBACK 6 FEET NUMBER OF BEDROOMS NOT TO SCALE GARBAGE DISPOSAL UNIT _>�Q MIN. SIDE SETBACK _/w�� FEET TOTAL ESTIMATED FLOW MIN. REAR SETBACK !' FEET (Ils2_GAL./BR./DAY X -3 BR.) 2ZO GAL. /DAY' REQUIRED SEPTIC TANK CAPACITY 41.5 GAL. ACTUAL SIZE OF SEPTIC TANK 4o GAL. LEACHING AREA REQUIREMENTS j y PERCOLATION SOIL TEST P-7s36_ r- %o StDEWALL AREA 2,.� GPD./S.F. BOTTOM AREA DATE OF SOIL TEST '�6 �, �.. al /4 sa 86 r �--�- 5IDEWALL 2TI (/2 /2) )SF x z.5 GPD/SF = Z? 7 GAL/DAY TEST BY (�f ,&1, �Nv✓ f4Cwefxd•f'_[✓A�N BOTTOM 1T 3 ( /Z 2) SF x 40 GPD/SF = /12 GAL/DAY WITNESSED BY g/c�aa /6 G�'n<rke04 ce*lc r.n.`I� "r ' PERCOLATION RATE Z�O MIN.. INCH 0.: � . . DAY _ 2 6 SF GAL/DAY / I M , to- Lot r 41 � - I I TEST PIT #1 TEST PIT #2 BREAKOUT CALCULATION: V - ELEV.— ELE .— 4 7� 74 I r —0.00 --0.00 sb BM LF corner:_basrn \ i i -1Pp� S — 0.5r"c7e _ n , " i�g- Ai r � Basrn ``, �// ! 84 SaM11f� l LE Stone �\ \ �'�/ p LEND: 1 =- �4 war of �,* �/ EXISTING SPOT ELEVATION OOXO ( EXISTING CONTOUR 00 - / � N FINAL SPOT ELEVATION 00.0 LOT 42 ` FINAL CONTOUR ,P 22,510 s ft. SOIL TEST PIT LOCATION o _ i q' BOTTOM OF TEST HOLE BOTTOM OF TEST HOLE -7 z, t OR WATER ELEV. TOWN WATER W W 1' Asph. berm typlcx�C SEPTlC: TANK o a DISTRIBUTION BOX ❑ L11 O 1 d' PRIMARY LEACHING PIT O WATER LEVEL ADJUSTMENT: / r . .,. } LOAM RESERVE 'LEACHING PIT .R PILE ,.98 TO BE REMO m o I TEST DATE WATER LEVEL �` INDEX WELL Q ` ,'`BdS-In \ ` cA� WATER `LEVEL RANGE ZONE 1 .� 3� a INITIAL ISSUE SAK/ X ,. •� , DEPTH TO WATER LEVEL FOR INDEX WELL N0. DATE DESCRIPTION BY 5. + Lot 40 3 FOR MONTH OF: ` SITE PLAN & SEPTIC DESIGN Y: . : ' \ WATER LEVEL ADJUSTMENT 1. 4 DELL AVE. DEPTH TO HIGH WATER . IN LOT 2 BARNSTABLE, MASSACHUSETTS FOR90 , OF Qs THEO CONSTRUCTION CO. APPROVED: BOARD OF HEALTH . STEPHEIJ ALLYN S WILSON " SCALE: 1 = 40 JOB NO. 1241 / 1241 46 T SITE PLAN DATE AGENT ,c LEVY, EDREDGE & WAGNER ASSOCIATES INC. PERMIT # dd fry B CR= IJWAH ARCHIrECTs pLANN%RS LAxD sURveYORS 889 WEST MAIN STREET CENTERVUIJ E MA 02632 W EN GLAND R PR S&SUPPLY CO.NE EGLA 0 GRAPHI E O C `;