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Home My WebLink About0045 EASTVIEW TERRACE - Health 45 EASTVIEW TERRACE j A= 029 037 !,pI a-rs 64 3 AY►�+_1..1 Commonwealth of massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments e✓rg -e Property Address L4S5el C✓e- �-Z2v► Owner Owner's Name M I �� information is / `a fs O�s /4/, required for every � �� i•7 page. City/Town State Zip Code Date o I ion 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. tmpat3nt when filling out forms A. General Information on the computer, use only the tab Inspector: A-15 key to move your cursor-do not 7 I.Se- use the return �f key. Name of Inspector Company Name `, Company Address •� City/Town State Zip Code Ste) 975— ?2�/ �o�� Telephone Nurhber License Number B. Certification 1 C> I certify that I have personally inspected the sewage disposal system at this address and thatthe CD information reported below is true, accurate and complete as of the time of the;inspection. The ins '. ion was performed based on my training and experience in the proper function andImaintenance�of on'sj e sewage disposal systems. I am a DEP approved system inspector pursuant WI Section 45.3404 Title 5(310 CMR 16.000). The system: a Passes ❑ Conditionally Passes ❑ Fails - CD ❑ Needs Further Evaluation by the Local Approving Authority /o i3 // Inspecto Signature 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, K 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. t5ins•11110 T'ele 5 Official Inspection Form:subsurface Savage Disposal System•Page 1 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments /-/S Property Address / �et TZ.2✓l II Owner Owners information is required for every page. City/Town State Zip Code Date of I n6pection B. Certification (cost.) 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 t-te 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 immin ent. P System will ass Y 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): t5ins•11/10 Title 5 Official Inspection Form:SubsuAaoe sewage Disposal system•Pape 2 of 17 Commonwealth of Massachusetts ft UgTitle 5 Official Inspection Form N Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address 11 Owner Owners Name information is i�Gf.rs�D vl s / 'i�/S / "�✓� �0�6 7 d l0 / /� required for every page. city/Town State Zip Code Date of Ins6ection B. Certification (cunt_) 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): 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 t5ins-11110 Tolle 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsuftce Sewage Disposal System Form - Not for Voluntary Assessments L .S �gs�tr/e�✓ /2yr Property Address Owner Owner's Nameinformation is required for every /j/] o�k7 page Cityrrown State Zip Code Date df Ins Tbon B. Certification (cunt.) 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 130 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 fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must Indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ R111" 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 above outlet invert due to an overloaded or dogged SAS or cesspool ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less than 'h day flow tsins-f fno Tale 5 Official Inspedion Form:Subsurface Sewage o4osei system-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address W�/ �ZPriI Owner Owner's Name information is /' '/Gt -s/r0✓ls / "/�/S i�%� �o�`�lJr required for every Me. CityfTown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ R-� Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ 2 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. ❑ E3--- Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ Q� Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ E4 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 collfonn bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or Bess 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. ❑ O,,�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 CM'R 15.304. The system owner should contact the appropriate regional office of the Department. t5ins t t/+o rule 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4S ZG'5 Tyl-e it,/ / �✓/ Property Address Owner Owners Name i1 //� � � information is /�a✓s-!10 � t/ c�h`rD /o required for every page. City/Town State Zip Code Date of Ins ion C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No L� ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ R Were any of the system components pumped out in the previous two weeks? L�' ❑ 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) L�" ❑ Was the facility or dwelling inspected for signs of sewage back up? L� ❑ Was the site inspected for signs of break out? LEI ❑ Were all system components, excluding the SAS, located on site? I� ❑ 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? E LJ 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): �c DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): r�O t5ins•t 1Ho T-69 5 Official nspedion Farm:subsurface Savage Oisposel hem•page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form va ' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments LIS CGs4oet✓ T-ev�- Property Address // ( e i T2e 0 Owner Owner's Name AW informations 6z✓S 01 S �/ b tf O /required for every page. Cityfrown State Zip Code Date of ftpedtion D. System Information Description: / Soo 6-,,11o, 'O's�"4,-�40 6 �;< 6 . 0 Number of current residents: Does residence have a garbage grinder? ❑ Yes Er--'No Is laundry on a separate sewage system? [f yes separate inspection required] ❑ Yes Duo Laundry system inspected? ❑ Yes 2'*-N'o Seasonal uses ❑ Yes Yam^' ry� o Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes No Last date of occupancy: Cat Date Commerciallindustrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per y tspol 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: t5ins•11/10 Title 5 OffidW Inspection Forth:Subsurface e �9 System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owner's Name f /Vd o information G✓,SJ�7 7S A/Af Al� 0'1 /0//S/// required for every page. Cityrrown State Zip Code We df Ins on D. System Information (cunt.) Last date of occupancy/use: Date Other(describe below): General Information cr /Ji-Pumping Records: //'' 0 Source of information: - �vs C71- 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) ❑ ►nnovative/Altemative 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): t5irts•1 vt° rage s Off'16W i nspection Form:Subsurface Sevage Disposal System.Page 8 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments \Vi f a5 Vl-e ?Q 0/ Property Address le- Owner Owner's Name information is GAS 0✓f f required for every page. City/Town State Zip Code Date of I nsp6ction D. System Information (cont.) Approximate age of all components, date inst lied (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron 40 PVC ❑ other(explain): i Distance from private water supply well or suction line: /Ofeet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: feet Material onstruction: concrete ❑ metal ❑fiberglass ❑ polyethylene y ❑ 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: x to Sludge depth: rsns•11110 Title 5 Official Inspection Form:Subsurface Sevrage Disposal System.pegs 9 of 17 �l Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address 6"�� 2-e Owner Owner's Name 1 information is required for every pag Cdy/Town State Zip Code Date df Ins eaion D. System Information (cunt.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): vt LM ►h 00 T rke'C C-1 is ✓"1 e �— A rA c'J 74!-0 l /✓r 6VOC/ � V Lea4✓, 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 t&M•11110 Title 5 MCW Inspedion Form:Subsurface Sevage Disposal System•Page 10 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments L S �cs�yre�,✓ err Property Address C✓C i �ze� Owner Owner's Name information is 404 11"'I'llI A4 0o,1b VY 10117111 required for every page. Cityrrown State Zip Code Date f I on D. System Information (cunt) 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.): t Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No (Sins•11No rule 5 official In spection Form:Subsurface sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments LIS Property Address Owner 1�( � �( information is Owners Name 7-�S / I Ar �/J' Q� `0 A? �� required for every page. Cityrrown State Zip Code Date of Irkpeciion D. System Information (cont.) Distribution Box (if present must be opened) (locate on sit plan): Depth of liquid level above outlet invert L ye 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.),. 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: t5irm•11/10 Idle 5 Official nspedion Form:Subsurface Sewage DPI System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora ' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,,11 Las S L G S 7 Vrf L✓ Te✓/ct c�- Property Address Owner Owner's Name / information is required for every page. Cityfrown State Zip Code Date o I mpktion D. System Information (cunt.) Type: Q/ 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.): X/ i / V O J� Nf o� At-) /Grti�c °Ir /GI/Yr 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 i Indication of groundwater inflow ❑ Yes ❑ No t5irm 11/10 rdie 5 official Inspection Form:Subsurface Sevage Disposal System-page 13 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Lf S Terms Property Address / Owner Owner's Name A //�iJ� 0 information is (,tls p HS / j /// �6 '� v/0 /� required for every Cdy/rown State Zip Code Date of I ction D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5irs•11110 'Ne 5 MaW Inspection Forth:subsurface Sewage Dispose]system•Page 14 d 17 !C,\-, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �fS 2�slvrLl 7'-ev�- Property Address Owner Owner's Name 1 /��//�J /� information is �4&�s A /�/T required for every page. Citylrown State Zip Code Date 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 public water supply enters the building. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately Q I ' ds _q ffAs �� Co✓'or Je- I, !sins.11/10 rtlle 5 Olfiaal Inspection Form:Su6surtace Sewage Disposal System Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for voluntary Assessments 9S ��Sfv%ow j-e✓✓ Property Address Owner Owner's Name information is /S Hf i ''Ar ()otb 0-9 10 /-7 11 required for every page Cityrrown State Zip Code Date o I ion D. System Information (cunt.) Site Exam: ❑ Check Slope ❑ Surace water ❑ Check cellar ❑ Shallow wells 40 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) L� Checked with local Board of Health -explain: ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: [I V7 S-4c, Ile cj/ 11-le V- plei t,9 Before tiling this Inspection Report, please see Report Completeness Checklist on next page. L't5im•11/10 Trtle 5 Off al Inspection Form:Subsurface savage Disposal syslem•Page 16 of 17 a Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 7S �of 54yie t,/ %e el- Property Address Owner Owner's Name information is /. f S /"//¢ Qo� r�� 0 /,31111 required for every f page Cityrrown State Zip Code Date of I pe on E. Report Completeness Checklist Ea/1'nspection Summary: A, B, C, D, or E checked [Inspection Summary D (System Failure Criteria Applicable to All Systems) completed 'System Information- Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•11/10 rdle 5 Official Inspection Fofm:Subsurface sewage Disposal System-Page 17 of 17 ♦: . k ' - � . t s ,.f.��. - TOWN OF BA.RNSTABLE LOCAT10fI &,u\ `a Al-,! SEWAGE # YMLAGE RY1 «6Y,,1 VA ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 1S0 C� LEACHING FACILTI'Y: (type) c�, P►T (size) VC)n C) c� NO.OF BEDROOMS BUILDER OR OWNER (P n tT,(.S tct,— UPDATE: lc-.A ssh-�)_COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the-gotta... LA 0 ' Feet Private Water Supply Well and Leaching Facility (If any wells exist I on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any.wetlands exist , within 300 feet of leaching facility) Feet Furnished by 7)�Lu a,_T�) i t, 2 � 3 A- �`� - LiS m _ COMMONWEALTH OF MASSACHUSETTS F�� 's \ EXECUTIVE OFFICE OF ENVIRONMENT AAII DEPARTMENT OF ENVIRONMENTAL PR CTT Wh 6 19g� 02108 (617) 292-5 ONE WINTER STREET, BOSTON MA UDY CORE WILLIAM F.WELD �a Secretary Governor DAVID B. STRUHS ARGEO PAUL CELLUCCI Commissioner Lt. Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM h P(` — PART A W I/ O�� CERTIFICATION �� ZSS�Y►�k1 I(.cc. t 0A*5 {;+.5 M&S. Address of Owner: Property Address' (If different) Date of Inspection: (G 115 r Cl ; Name of Inspector M ,. r\ 1� L I am a DEP approved system inspector pursuant to Section 15L of Title 5 (310 CMR 15.000) Company Name: tn Mailing Address: Telephone Number: 1; �, CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address`and that the information reported below is true. accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance' of on-site sewage disposal systems. The system: Passes A _ Conhionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (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 al Protection. The original should be sent to the system owner and copies sent to the appropriate regional office of the Department of Environment rov . ble and the approving authority. buyer. if applicable, pin P INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. 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. Indicate yes, no, or not determined (Y. N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. _ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection: or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. Page 1 of 10 (retired 04/25/97) r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM t s PART A VS11 1 ACERTIFICATION (continued) . Property Ad ess: t'I , Owner: k Date of InsJp�ectio :ate.; BJ SYSTEMC OND IONALLY�PASSES (continued) '•`Sewa a backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to broken. settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). Describ observations: broken pipe(s) are replaced obstruction is removed \ distribution box is levelled or replaced The system requi d pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval o the Board of Health): b 1 ken pipe(s) are replaced ob ction is removed C) FURTHER EVALUATION IS REQUIRED Y THE BOARD OF HEALTH: Conditions exist which require further evalu ion by the Board of Health in order to determine if the system is failing to protect the . public health. safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF ALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIOhZtiG IN A . MAINNER WIUCH WILL PROTECT THE PUB IC HEALTH AND SAFETY A.N`D THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of a surfa water _ Cesspool or privy is within 50 feet of a borders vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HE (AND PUBLIC WATER SUPPLIER, ff APPROPRIATE) DETEILNUNES THAT THE SYSTEM IS FUNCTIONING A DIANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONI-NIENT: The system has a septic tank and soil absorption system ( S) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. T The system has a septic tank and soil absorption system and SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the AS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the , S is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for colifotm bacteri and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nt ogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not id). 3) OTHER (revised 03/25/97) Page 2 of io • y • r \ Su.BSURFACE.SEWAGE_DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) :rtv Addrrss: w .>•c... of Inspection: t ;YSTEM FAILS. . - •'No" as to each of the following must indicate either 'Yes o. Health should be contacted to determine what will be necessary to cornea t have de termined that the system �ielates one or more{of following failure criteriala` defined in,310 CMR 15.303. The oasis for this determination is identif►ed below. She Board o _ the failure. No into facility or system component due to an overloaded or clogged SAS or cesspool. _ Backup of sev.a ga {effluent to tl;e�surface of the ground or surface waters due to an overloaded or clogged SAS or ,,.,bischarge or^pond�ng o ' . — cesspool. Static loud level tot he distrib.ition boy above outlet invert due to an overloaded or clogged SAS or cesspool: — is less than 112 day tlov• volume _ _ '1 ble va u below invert or oval a , _ Licuid depth in cesspool is less than 6 f __ ar. a times in the last year NOT due to clogged or obstruaec Required pumping more ch pipe's • _ ►.umber o'times pumped �• _ Any port�o� o'the Sort Aosor�uen 5�'stem, cesspool or pri • is below the high gr°undN'ate• e'e�•att0� Hater supply• An. por::or+ of a cesspool or pri.ti is n'ithir. 100 feet of surface water supply,or tributan to a surface _ •withjr.-atone I o a public well.' _ Any potion of a cesSDoo• cr.privy i5 qp% pe^.io- o:a cesspool or pr►.Y is within SO feet a private water supply well polv no m a _ Am•porlo r. o:a cesspool or privy is less than 100 eel but greater than SO f abie�attach ric°p�' of well uwater analysis hfor "— a:ceo:able ware, qualit\ anal�•sis. li the well has _n analyzed to accep coldorn: bacteria volatile organic compounds, a monia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: g. `rou must indicate either :Yes' or 'r.oioaaf oast hemshn adeat of to the criteria above: The iolio-mg criteria aop g- the The system serves a {acilin with a design flow of 10 OQ e� m greater f the following conditions exist.m is a significant threat to public health and saiet) and the environment beta Yes No . _ the system is within 400 feet of a surfs a drinking water supply the system is within 200 feet of a trib tary to a surface drinking water supply .— -- Zone 0{a the system is located in a nitrogen nsitive area (Interim Wellhead Protection Area -IWPA) or a mapped -'— _ public water supply well) e groundwater The owner or operator of any such system shall bring the system facility aoffice of the Deipartmentance t for hfurther in ormationtment program requirements of 314 Ch1R 5.00 and 6.00. Please consult the eg i _SUBSL.tRFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address::-4S�K[\j -zv) Owner: Date of Inspection: y b Sul z 5 . ...... ._ � .:. . . . .-• . _ . ._ � . _ Check if the following have been done: You must indicate either 'Yes'or -No-as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. - : Hone of the system components have been pumped for at least two weeks and the system has been receiving normal (loud rates during that period. Large volumes of water have not been introduced into the system recenth or as part of this inspection. _ As built plans have been ocatned and examined. Note if they are not available with NIA. _ The iac:hti or d%%etling %vas inspected fa+'signs o-.sewage•back-up.. y'C _ The sx•ste n does not receive non-sanitary or industrial waste flow. - �" _ The site %\as inspected for signs of breakout. the So+1 Aosorptton System, have been located on the site. All s�•sterr. components, excluding The septic tank rranhoies were uncovered, opened. and the interior of the septic tank was inspected for condition ai_banies or tees. matertai o:construction, dimensions, deptn of liquid,depth of sludge,depth of scum. The size and location of the Soil,Absorption Svstern or: the site has been determined based on _ The iac,ltt% o�+ne• nano occupants, if dtfterertt,trorn owner were provided with tniormation on the proper matntenance of Sub•Suriace Disposal System.. _ _ Existing iniorrrtation. Ex. Plan at B.O.H. _ De;errnined to the iteld sti am of the failure criteria related to Part C is at issue• approximation of distance is unacceotabie (15•302:3t:bt! SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION roperty Address: "l$ '40,5 lJk iwner: W to-17R S lC . rate of inspection: Ad s y C G FLOW CONDITIONS tESID�—: )esign flow:��•pA./bedroom for S.A.S. lumber of bedrooms: Qa lumber of current residents:�t Z ,arbage grinder (yes or no): t-J- aundry connected to system (yes or no): ;easonal use (yes or no): N Mater meter readings, if available (last two (2) year usage (gpd): L� iump Pump (yes or no): (`� Last date of occupancy: CON LNIERCIAL/INDUSTRIAL: Type of establishment: Design flow: gallons/day Grease trap present (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Tide 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GEN-ERAL INFORMATION pUNIMG RECORDS and source of information: System pumped as pan of inspection: (yes or no)-L+RD If yes, volume pumped: gallons Reason for pumping: TYPE 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) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: T 1`I`rI`l1 Sewage odors detected when arriving at the site: (yes or no) Page S of 10 (revved 01125197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: (uN►>�CSI(�il. Date of Inspection: BUILDING SEWER:�Cb (Locate on site plan) Depth below grade: Material of construction: _cast iron _40 PVC _other (explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) 'SEPTIC TANK:(} (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain) If tank is metal. list age _ Is age confirmed by Certificate of Compliance _(Yes/No) Dimensions: i<C U Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: � Scum thickness: O Distance from top of scum to top of outlet tee or baffle: L Distance from bottom of scum to bottom of outlet tee or baffle: t 4 v How dimensions were determined: Comments: (recommendation for pumping. condition of i let and outlet tees or baffles, depth of liquid level in rela ion t outlet inve structural inwerity. ' nce of Ieakace. etc.) ?� L —o t, d t �� Z6— ) GREASE TRAP:_&A-�t (locate on site plan) Depth below grade: 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: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert. structural integrity. evidence of leakage, etc.) ed 04/25/9 e 6 of 10 (revu '7) Pa g f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C c SYSTEM INFORMATION (continued) Property Address: Ly 20�1<('j Owner: tt�Si�(,� Date of Inspection: TIGHT OR HOLDING TANK: (Tank must be pumped prior to. or 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/day Alarm level: Alarm in working order _ Yes. _ No Date of previous pumping: Comments: (condition of inlet tee. condition of alarm and float switches. etc.) tISTRIBL'TION BOX:�S (locate on site plan) Depth of liquid level above outlet invert: i;t 40C."'f�''14�f . P q —0 Comments: ' (note if level and distribud is equal. evidence of soli carryover, evidence of leakage into or out of box, etc.) C G iV �Kk iC, . PUMP CH.AINIBER:L (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.) (revised 04/25/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 4S�i�Ti�l�vJ Owner: AX<SlG Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible: excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number:�l.iel. leaching chambers, number:_ leaching galleries, number: leaching trenches. number.length: leaching fields. number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: A(ne condition of soil, sitins of hydraulic failure, level of ponding, c ndi d n of vegetation, etc.) CESSPOOLS:. � (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 (cesspool must be pumped as part of inspection) 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.) (revised 04/25/97) Page 8 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORA PART C T SYSTEM INFORMATION (continued) Property.Address: Owner: tmXt51L,- Date of Inspection: Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting property,.observation hole, basement sump etc.) Determine it from local conditions " Check with local Board of health Check FEMA Maps Check pumping records Check local excavators. installers Use USGS Data Describe in your own wor w you established the High Groundwater Elevation. Must be completed) f. (revised 04/25/n P2ge to or to � C SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Addressi 6(s �R Owner: VAJ.,tSrGla- Date of Inspection: 16(t S(y SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) �J Al � z - y � r +63 .3C1i' y ALt by %ii �u AS- LW (revised 04/25197) P2ge 9 of 10 TOWN OF BARNSTABLE , "� CATION � 0 � EWAGE # O L' VILLAGE "�N (CL ASSESSOR'S MAP & LOTO� !3 27 INSTALLER'S NAME & PHONE NO. �r== SEPTIC TANK CAPACITY 4f . LEACHING FACILITYAtype) Z) � (size) /f DO NO. OF BEDROOMS PRIVAT WELL OR PUBLIC WATER BUILDER OR OWNER " U C1/) CCW&S-T8KUe-Q7k DATE PERMIT ISSUED: r A �v DATE .COMPLIANCE ISSUED:.. VARIANCE GRANTED: Yes No _ 1 .r, � /n1 1 ' I i z 1 �--a � i �- ( `� � ,�� ,d r �— �� —� �/ _ � ��_� � �,r __ �y ' _ -- . , . ._ _ �� _ _ } FEB.... A0........_ THE COMMONWEALTH OF MASSACHUSE77S BOAR® OF HEALTH ApplirFatiaan for Disposal Warks Tonstrttrtiaan Prrutit Application is hereby made for a Permit to Construct ( 4r Repair ( ) an Individual Sewage Disposal System at: _J Location-Address or Lot No. ..._...N � ...._ .................................................. ..........•------.......---•-•---•--•-----------------....---••-----•--.......----._.....-•------- W Owne Address .........-- - ---•---• •---- ........................................ ..............................•--•---•--•-..........----...----•-----------.....•--•---------•--- r UType of Building Installer Address Size Lot_.___...!___ __ ___Sq. feet _____Dwelling—No. of Bedrooms............. ..........................Expansion Attic ( ) Garbage Grinder ( ) `4 e of Building a Other—Type g ------------------•--------- No. of persons...... ................ Showers ( ) — Cafeteria ( ) Otherfixtures ---------------•------•-----------•-....._----- •-----------------...-----------•--- w Design Flow.............. _`am..D........... per person per day. Total daily flow..__.44 _ ___..._ __....______gallons. WSeptic Tank—Liquid capacity__2'50 allons Length_do` _ WidthU01___ Diameter________________ Depth;.".',�t_ "_.. x Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.-.-.!-------------- Diameter_ ........ Depth below inlet_!A,P�...... Total leaching area% .....sq. ft. Z Other Distribution box ( Vf Dosing tank ( ) ' l P- 3��3 aPercolation Test Results Performed by- '� __. _.._! i_J,lL_+------------------------ Datt�a_�� q '___ minutes per inch Depth of Test Pit___J___l1____.______ Depth to ground water_. ___._. ,.a Test Pit No. 1----�__....... p p P gr - 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 9 ............................................ ........................................................................................................... O Description of Soilµ w UNature of Repairs or Alterations—Answer when applicable................................................__..........................._.................. --------------------•----•-----•••---------•--------------•----------------------••••---........--------••-----------------•----•-------------------•--------•---•-------------••-•------•---------•---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITL 1E 5 of the State Sanitary Code—Th undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by e board of lipli Le— Signed..--- ...... ------------------ _ Application Approved By... -- - - ...................................................... -•----- YDaj Co te Application Disapproved for the following reasons---------------------•---------------•------------------•------•---------------------...-•-----•---•--------•---- ......----•--------••----------------•--..--•---•--•------....------•-----•---------.....------------_--_..__...-----------------•---------------•-------------------------------------------------_-_--- Permit No.__ ��.� Date ....._----•----•-•-------•--- Issued-------------------------•-------------•- . Date y THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �....1: � OF...2 ...t.l.:Yl r�.........C- Appliration for Diipusal Narks Tonstrnrtiun Frrutit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: .._ � .... Location-Address or Lot No. Ali t I 0 _ --- ---------------••-•-•---------- ------------- wne Address W _ i Installer Address UType of Building Size Lot_J_ _._."_:.___________Sq. feet .t Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aa Other—T ype of Buildin g ............................ No. of persons-----��-•--.---••------- Showers ( ) — Cafeteria ( ) � Other fixtures W Design Flow.............::J......-.....,.._,`-C,_gallons per person per day. Tot a1.daily lflow.....y`4 -............................gallons. WSeptic Tank—Liquid capacity..,........gallons Length��%U___- Width)C---... Diameter................ Depth __."._- x Disposal Trench—No..................... Width...................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.___`_______________ Diameterc'..t __..._ Depth below inlet :j..��......... Total leaching area `Uf....sq. ft. z Other Distribution box ( Dosing tank L V n .• r .. Test Pit No. 1__. "__..._..minutes er melt Depth �,`�(� Date:_�� ..(._....`!_...................._ Percolation Test Results Performed by.":.......................................... . p p of Test Pit..'..1.............. Depth to ground water.._`:.................. f= Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Ix . •----•------------•--......: Description of Soil : -----•------ :__........ --.-•--- -•• ----------••-•----------------------------------- ---------•--------------------------------------------- (� ------------------------------ ---— t�� .`�i[-- ----- r�"l.lC�� W UNature of Repairs or Alterations—Answer when applicable............................................................................................... -------------------- -------•----------......--------------•------•-----------...---•----...---------------••------------------------•-------------------•--------------------•-•-------......-•--••---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T I A'12 5 of the State Sanitary Code—Th undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issue he board of Peal Signed-- .....4-----•-------.-•- .__t��1�V'-----.:�!� �1�.(.. ............_.... Da Application Approved By. ._____C!_ �'!�."_____._ 7 ` ............. ........ . /a ate �._.._.. Application Disapproved for the following reasons:-------•-------•-----------------------------................................................................. --•..............................................................•-------•------•--......---••------•--------•--•...-•-------------•-------••------•-•----------•-•-••---•-•--•-------•••••---.....---- Permit No.--•----•--•----= .................................. Issued_ .Date - Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH � / �� / � �n� yyyQQQ ................................ ........OF? .............................. Q10"rrtifiratr of Tuntphaurr T IS IS TQJER IFY, hat th ndividual Sewage Disposal System constructed ( or Repaired ( ) Zo at has been installed in accordance with the provisions of TITLE 75 of The State Sanitary Codp as described in the application for Disposal Works Construction Permit No.....`_. ._--__ ........ dated_- . THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE..................... '.. ... . -'-�-�•........................... Inspector..................... r ............................................ THE COMMONWEALTI4 OF MASSACHUSETTS BOARD OF HEALTH NO..._........ FEE........- -•.......... ��/tr uan rrntit Permission is hereby granted---- J+ii •--- tf ----------------•---•--------•--..--------...------.--.-.---••---•-.--.---•---•-•--- to Construct ( or Repair ) an Individual Sewage Disposal ystem at No.... ^+ ...................................................... treet r, i-Y / ✓ as shown on the appli tion or Disposal Works Constructio ermit N`:• =f Dated -- -----..... =.... _ Boar of Health DATE •- FORM 1255 HOBBS a WARREN, INC., PUBLISHERS S YS EM PROFIL NOT 70 SCALE TOP FDN. FINISH GRADE FINISH GRADE O VER FINISH GRADE OVER GIST. BOX .9 FINISH GRADE OVER SEPTIC TANK 9 a, o LEACHING PIT D VARIES / .�" OF 1/8 12" MAX 0.., 0 •p' .•°:.O• •'e ...e,.-,p.:•'G1•.t:•D:'0.:.:D:.d:� :e•;o.•: • 'O•. •e.'t: •.p'0: :�. .• o.:b D.:.:. :q:::p,: .p:..:e:.:•s'. .o. :p.. :e:. ..:o:. a:a-o: o PRECAST CONC. OR D ASHED PEA STONE D. •.°.:. , :e s e:.e o -' BRICK 6 MORTAR 9 OUTLET PIPE LEVEL TO 12" BELOW GRADE O b:d. 'a 6 FOR 2 FT. MIN. ;poe'.:o'onrooe tp p:Q:D:oO._oo..•.o.••o:,j :o:rq;us p: q :e Q. .91 o D .a' 91 90 �'�" 0 ;e e:::.:e'.:,.o..i o D :b.'.D.. •o.o. f! o. 6 p e .A�; o ° ` °:•o'� o:D o C. I OR PVC TEES .a ®.5o i,3G' l0?•.Do.• D• a D. :j;o •• 0: 'e: . .•, a is :.C: '0 BSMT. FLR. :o°°•: /z 5- GALLON y'p/ lV BOX TR.rI,L7 V TION GJ O 87 s CIS „ ., a 6 ' 4: o: •o.'e.•..D .. PR,ECA S T CONCRETE INSTALL ON LEVEL BASE 3/4 TO 1-1/2 ?; PRECAST A o.•o o..b: •D;•: o .. o: b :.; .e.,.p• o.•.a:o: e WASHED :a H-- f 0 RE.1'NFORCED �` • CRUSHED � CONCRETE T, �•o:o' :�:o-o':o: R:o:::o-:o:e•o.e:a_, Q• :p.o Q.e:.::.e•: 6• e,: a'o':o: STONE •a ° .o• A:° °-• .°:. °:. o b:° I': d. �! 0:. H / V REINF a . SEPTIC TANf+C a. : o a• `p, ho:I INSTALL ON LEVEL BASE ? 9 �" ° ° ° a• . :0,'p:o.. •. p NOTE.' EXCA VA TE, TO ELEV. P. OR ,�• � 'a �' ° °D. a . . L OWER TO REMO VE ALL IMPERVIOUS — c•_ _ ^''` MA TERIA L BENEA TH THE L EA CHING AREA REPLACE EXCA VA TED MA TERI'AL WI TH � CLEAN, CLA Y FREE SAND ob EFFECTI VE DIAMETER f V0�/ �� R,4L,. NOTES LEACHING PIT GENE I 4 SED ON A's s u n, G'P INSTALL ON LEVEL BASE �=. - A�.:.L ELEVA TION� SHOWN ARE ��, �. x J 2. ALL PIPE, im T!-✓E .S YS TEM' MUST BE CAS T IRON a j - , _ OBSER VA TION ICI r ii. ! UP S[:HE,,ULE � r� VC." F` THE BOARD OF r✓,EAL TH MUST'RE NOTIFIED \ ? / WHEN CONSTRUC rION IS COMPLETE PRIOR �•----' TO SA CKFIL L IN w PERCOLATION RA TE.• v 2 MIN./IN. �' ,�.30,3 ~\, 44 ' 4. ANY CHANGES`I.✓ THIS PLAN MUST BE APPROVED BY THE BOARD ?F HEALTH AND CAPE G ISLANDS WITNESSED BY.• � SURVEYING CO.; INC. T. 5. MA TERIALS ANC' INS TALLA TION SHALL BE IN gyp.,; �•7rn S. BRO. OF HEALTH DE,1576N DA TA COMPL IANCE WI TH THE STA TE SA NI TARY � • DA TE.' �' x c i p8c ` CODE - TITLE � - AND LOCAL APPLICABLE � - -' - - "$ '< �� 4 RULES AND RES'/LA TIONS r2Sa sA _ \ , NUMBER OF BEDROOMS MtCAST. Oil fT y-L ;tip �' r 6. NORTH ARROI .I , ,FROM RECORD PLANS ANO Septic An �` �� '� ,%`r IS NOT TO BE-: :3ED FOR SOLAR PURPOSES GARBAGE DI,3AOSAL 'Yd Tap o, i 7. FLOOD HA IA RD 'ONE C DAILY FLOW < � GAL . a -- e -- B. WA TER SUPPL Y ��w ;- ' // SEPTIC TANK REO 'D. GAL . SEPTIC TAN; PROVIDED GA L LEACHING REQUIRED GPD. ,R SIDEWALL AREA ,� isa S. F. PfI�CAST CONC ET� San d LEACHING PIT � Aso S. F.X 2,_.�-`.G/S. F._ ��'6 GPO 9� BOTTOM AREA �-o S. F. n ti h ;' X % G o f- <,,, LEGEND c�,.. -La S. F.X /,C"I G/S. F. _ �o GPD o T 3 ` �o� , w. ,�.., ss.o L EA CHING PRO,/IDED S_ GPD q ��i �� ' -- _v 07 c a.•> � �---P,,7 POSED ELEVA TION �[� y 2 �,�.S ( ' �r ' - �'.6"� , y` � g�9 .�' W�tr., ,i,', , -- 92 --- Lya'ISTING CONTOUR ' 4� 1�. JJ'F•gear S•I, �•o��i� k `,� SINGLE FAMIL Y RESIDENCE & 1 p C,3SERVA TION PIT ❑ O.TSTRIBUTION BOX �c. r / fPi� ;:`� r o,� RUIN �c�c��R, PROPOSED SEIYA GE DISPOSA L S YS TEM / r, 5z:so d Q L ACHING PIT BERTQ N°a �„ }1 N0. 2>3sa PREPARED FOR S, PTIC -TANK � ';;�� '``tj, LIAMES. GUILD LOT 3 EAST VIEW . TERRACE MA O - SS ,RP, -SERVE �,,,� �f ��QSJa, MAPS TON N MILLS �3APNS MA DAVID \ PIPE INVERT ELEVA TION o/-,NICKI _5 �280II5 0 P ) DATE., F�� 1� ' CAPE 6 ISLANDS SURVEYING, INC. PLOT PLAN N SCALE AS NOTED P. 0. ; BOX 334 SCALE: 1 �� f SS• 5 4G0 ,;7 g ,3 � � _ N� _ `*' PLAN NO. ,5 ��" e T�ATf'GCET, l�fA n,T < ✓.{�;r_ e..