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HomeMy WebLinkAbout0039 GOLDENROD LANE - Health y Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t� ,a a< 39 Goldenrod Lane .? Property Address h Merrihew Owner Owner's Name information is X required for every G�ntel�re tjAjStn8 1S Ma 02632 6/28/18 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information L51 --t# (31 on the computer, use only the tab 1. Inspector: key to move your cursor-do not Chad Hathaway use the return Name of Inspector key. H.P.S. kCompany Name P.O.Box151 F0264Company Address Forestdale Ma 4 Cityrrown State Zip Code 774-274-2581 12866 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in.the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 6/28/18 Inspector's ature Date The system inspector sh �Itaopy 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. t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 1 of 17 Lv6ry4e 6-67 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M s•'°i 39 Goldenrod Lane Property Address Merrihew Owner Owner's Name information is required for every Centerville Ma 02632 6/28/18 page. Citylrown State Zip Code Date of Inspection 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: Septic functioning as designed. 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): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Goldenrod Lane Property Address Merrihew Owner Owner's Name information is required for every Centerville Ma 02632 6/28/18 . page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Goldenrod Lane Property Address Merrihew Owner Owner's Name information is required for every Centerville Ma 02632 6/28/18 page. Citylrown State Zip Code Date of Inspection 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 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 El ® 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 clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins-3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 39 Goldenrod Lane Property Address Merrihew Owner Owner's Name information is required for every Centerville Ma 02632 6/28/18 page. Cityrrown State Zip Code Date of Inspection 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. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any 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. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Goldenrod Lane Property Address Merrihew Owner Owner's Name information is required for every Centerville Ma 02632 6/28/18 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ 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? ® ❑ 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): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 39 Goldenrod Lane Property Address Merrihew Owner Owner's Name information is required for every Centerville Ma 02632 6/28/18 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes n No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current 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: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 39 Goldenrod Lane Property Address Merrihew Owner Owners Name information is required for every Centerville Ma 02632 6/28/18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: owner pumps every 2-3 years 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 System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)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): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Goldenrod Lane Property Address Merrihew Owner Owner's Name information is required for every Centerville Ma 02632 6/28/18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1999 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.5' feet Material of construction: ❑ cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: 10+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): no signs of leaks or poor venting Septic Tank(locate on site plan): 1' Depth below grade: feet Material of construction: ® 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: 1500 gal H10 Sludge depth: 2" t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M ,••''t 39 Goldenrod Lane Property Address Merrihew Owner Owners Name information is required for every Centerville Ma 02632 6/28/18 page. CityrTown 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 32" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? tape and sludge judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): pump every 2-3 years as maint. to protect leaching. tees in place no signs of leaks or concete decay 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 39 Goldenrod Lane Property Address Merrihew Owner Owner's Name information is required for every Centerville Ma 02632 6/28/18 page. City/Town State Zip Code Date of Inspection 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 El 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 copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3113 Title 5 Official Inspection 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 39 Goldenrod Lane Property Address Merrihew Owner Owner's Name information is required for every Centerville Ma 02632 6/28/18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 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.): level at bottom of outlet pipe. no signs of being overfull. no visable leaks or decay 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.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: no inspection port t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M ,••�''i 39 Goldenrod Lane Property Address Merrihew Owner Owner's Name information is required for every Centerville Ma 02632 6/28/18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 5 infultrators ❑ 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.): probed stone around chambers . stone was dry no visable ponding 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,•�' 39 Goldenrod Lane Property Address Merrihew Owner Owner's Name information is required for every Centerville Ma 02632 6/28/18 page. Cityrrown State Zip Code Date of Inspection 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.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Goldenrod Lane Property Address Merrihew Owner Owner's Name information is required for every Centerville Ma 02632 6/28/18 page. City/Town 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 � C� C� V3I � � I G s lyU 3 2 - lY _ 9z-f 3 _,,�3 N - 3Y _ y� Ste - 3 % t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 15 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,..�' 39 Goldenrod Lane Property Address Merrihew Owner Owner's Name required fo is Centerville Ma 02632 6/28/18 required for every page. City/Town 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: 25+ 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 with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: town GIS mapping You must describe how you established the high ground water elevation: lot el. 60' low in area 32' Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 f . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 39 Goldenrod Lane Property Address Merrihew Owner Owner's Name information is required for every Centerville Ma 02632 6/28/18 page. CityrFown State Zip Code Date of 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 ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 T V Z 4- � COMMONWEALTH OF MASSACHUSETTS. I EXECUTIVE OFFICE OF ENVIRONMENTAL-AFFAIRS DEPARTMENT OF ENVIRONMENTAL PR ECLO VED MAY 19 2003 TOWN OF BAfi�NSTABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:Qo Owner's Name. Owner's.Address: 3p Date of Inspection: MAC `a 01 7-'" Name of Inspec ple se. rint) — s r1 � l PARCEE, Company Nam LOT Mailing Address: 0 �� Telephone Number: `7 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was.performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: /Passes Conditionally Passes Needs Further Evaluation by the Local Approving.Authority ails Inspector's 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 apd 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. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different. conditions of use. Title 5 Inspection Form 6/15/20.00 page 1 Page 2-of l 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.A CERTIFICATION (continued) Property Address: 9aY1,4fys Owner. Dafe of Inspection. Ins.pectioa Summary: Check A,B;C,D or E/ALWAYS complete all of Section D A. S stem Passes: I have not found an information which y n hick 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: ;v,!>I ,y p B. Sysiem 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.. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. The septic tank is metal 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. ND explain: 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. i Sy' stem will ll pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page.".of.I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .PART A CERTIFICATION(continued) Property Address:. Owner: , ­n/.1 . Date of Inspection: 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 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 and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of l 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: ,tcl - Owner Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No/ V 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 invertdue to an overloaded or clogged SAS or cesspool _ Liquid depth in cesspool is less than 6"below invert or available volume is less than'/2 day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped _ V 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. _ V Any portion of a cesspool orprivy is within a Zone 1 of a:public well. _ Any 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less.than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] (Yes/No.)The system fails. I'have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correctthe 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• You must indicate either"yes" or"no"to each of the following: (The following criteria apply to large`systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply i the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—I WPA)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. .4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property.Address: Owner: XZ Date of Inspecticn: Check if the following have been done. You must indicate"yes"or"no"as to each of the followinz: Yes. No 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? r� 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 Was the site inspected for signs of break.out? Were all system components, excluding the SAS, located on site _ Were he 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? e site has been determined based on: The size and location of the Soil Absorption System (SAS)on the Yes no 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 15.3K(3)(b)] _ 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: J � Owner:• Date of Inspection: C0 _ FLOW CONDITIONS RESIDENTIAL, Number of bedrooms(.design): 2> Number of bedrooms(actual): DESIGN'flow based on 310 CMR 15:203(for example: 11.0 gpd x#of bedrooms): Number of current residents: Does residence have a garbage grinder.(yes or no): Is laundry on a separate sewage system(yes or no. . :[if yes separate inspection required] Laundry system inspected(yes or no) Seasonal use: (yes or no.)2(,Q Water meter readings; i}''av''aiiltable(last 2 years usage(gpd)): Sump pump(yes or no) /Z Last date of occupancy: COMMERCIAL/INDUSTRIAL Type of establishment: Desigr. flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sq.ft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: A4 Aw Was system pumped as part of th6 inspection(yes no If yes,volume pumped: gallons--How was quantity pumped determined? Reason'for pumping TYPE OF SYSTEM ✓peptic tank, distribution box,soil absorption system Single cesspool _Overflow cesspool Privy Shared system(yes or no)(if yes, attach previous inspection records, if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy'of the DEP.approval _.Other:(describe): A roximate aQe ofall c mpon nts, date insta d(if known)and source of information: Were.sewage odors detected when arriving at the site(yes or no��"' 6 Page 7 of I I OFFICIAL INSPECTION FORM-.NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner • A Date of Inspection: y�;� BUILDING SEWER(locate on site plan),' Depth below.grade: Materials of construction:_cast iron _40 PVC_other(explain): Distance-from private water supply well or suction line: Comments(on condition of joints,venting, evidence of leakage,etc.): SEPTIC TANK: (locate on site plan) i( Depth below grade: AD Material of construction: .-'concrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:— Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: 4- k Sludge depth: 9-y Distance from top o sludge to bottom of outlet tee.or baffle: Scum thickness: Distance from top of scum to top of outlet tee or baffle: y flo&el Distance from bottom of scum to bottom of outlet tee,or baffle: How were dimensions determined: " Comments(on pumping recommendations,Clet and outlet tee or baffle condition,structural integrity,liquid levels related to outlet invert, evidence of leakage etc.): 1i -Awla i p GREASE TR 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(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Page 8of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEM INFORMATION(continued) Property Address: OF Owner: Date of Inspection: o� 67 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(expiain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION-BOX: l/(if present must be opened)(locate on site plan) Depth of liquid level above outlet inverter Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover,any evidence of 1 akage into or out of box, etc.). � PUMP CHAMBER�.- ocate 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.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: ___ ` �C�i► Owner:.. Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): v""(locate on site plan,excavation not required) If SAS not located_explain why: Type _.__..._. 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. • o CESSPOOL (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.aroundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding;condition of vegetation, etc_): PRIVY:/h'jj� (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.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: ell AIARk., Date of Inspection. Qom? SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. t j ,3q 5 10 I f — - Page I 1 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: q Owner: Date of Inspection SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 7 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked, date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: -Checked with.local.excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: r �D Il Permit Number: Date: Completed by: � HIGH GROUND-WATER LEVEL COMPUTATION Site Location: -3. kold XI, C pl&IIL��lz Lot No. Owner: /' S 5 Address: / Contractor: � Address: � U,S�`7Y Notes: STEP 1 Measure depth to water table Conearest 1/10 ft. ......................................................................'.... ... .Date month/day/year STEP 2 Using Water-Level Range Zone and Index Wel'I Map locate site and determine: (A Appropriate.index well.................................................... . G Water-level range zone...:..........:....................................... STEP 3 Using monthly report "Current Water Resources Conditions" determine current depth to water level.for index well .......::.................. month/year STEP 4 Using Table of.Water-level Adjustments. for index well (STEP 2A), current depth to water level.for index well (STEP 3)., . and water-level zone (STEP 2B) determihe.water-level adjustment-................. STEP 5 . Estimate depth to high water by subtracting the water level adjustment (STEP 4) from measured depth to water level at site (STEP.1) ........... Figure 13.--Reproducible computation form. J IC r T WN OF BARNSiTA,B�LE LOIC`ATION 1 � C� t--d 1 • SEWAGE # � VILLAGE )knl'�) S ASSESSOR'S MAP & LOT n `1o.Z t INSTALLER'S NAME&PHO . N -I 14 /� -SEPTIC TANK CAPACITY LEACHING FACII.ITY: type) J, CTAcu�-AA (size) XC o NO.OF BEDROOMS BUILDER OR OWNER L rs �;Inne PERMITDATE: .1 ' "1 COMPLIANCE DATE: Irl 2? Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist 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 14bU Sf:, l7.aro Je A2-- 14 A �4� 7-7 : a 9 r No. r� f N Fee t� THE COMMONWEALTH OF MASSACHUSETTS - Ent e�edin computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Zippricatiou for Migogal *pgtem construction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 1-0-7 '„, t, Owner's Name,Address and Tel.No. Mbt/b�LA, f�W� L A RS 5"�P-e[i Assessor'sMap/Parcel 01(Du pWSVkC� �pfi� Cf�rJ l`✓��/]t.� Z©— ISSCi Installer's Name,Address,and fel.No. Designer's Name,Address and Tel.No. ge,V%L_PZQ0a-0-®dJSTP-vC:c10N (_1f,3(,iZMAN Zk28— Z59 Z, Type of Building: `' 0e�" Dwelling No.of Bedrooms 3 Lot Size IFS)3% sq. ft. Garbage Grinder(P) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures DesignFlow 33 t� gallons per day. Calculated daily flow gallons. g P Y Y Plan Date lfl,19 19 8 Number of sheets Z Revision Date Title .5rrf A tjo 54-pDc- PLn (v =0 V— Lt1kY_S 5;mQC. Size of Septic Tank /SOO Type of S.A.S. T2E4JGN roRa9zJ00 Description of Soil — 60Ar"V 59/U "—z " Lo,4m 5 S1L.-r­f�e6 /2e>" 0 XO -04esr sral ,VD Nature of Repairs or Alterations(Answer when applicable) 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 Certifi- cate of Compliance has been issued bv this Bo d o ealth. n d Sig Date Application Approved by Date Application Disapproved for the following reaso s Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of compliance THIS IS TO CE IFY, tat th Or1,-site Se Disposal System Constructed(�Repaired( )Upgraded( ) Abandoned( )by at /�Yl— I Aiasbeen constructed in accordance with the provisions of Title 5 and the for Disposalsyste Cons ction Permit No. - dated Installer r W'Aigner The issuance o th' t o e construed as a guarantee that the s ill func ' a d d. Date Inspector .. ! ...,A..t r� VV I���`�• r I� < ���� P� t�.J�--�� .�'-�' l F ^J"•N- ''-�.;� � 1f"_. No. Y* „" ' - � ` � Fee 10-1 T' THE COMMONWEALTH OF MASSACHUSETTS Etr fed in computer: j _ !1., Yes PUBLIC HEALTH DIVISION - TOWN OF,BARNSTABLE, MASSACHUSETTS w 2pprication for Oioozal *raem Con,5truction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 1-0-1 (�p`� mLA o Owner's Name,Address and Tel.No. T = Assessor's Map/Parcel -)Coo pL�SCaC� �pffi -G�r.JT ��/ltr��t. I�j i3o-� zo- IS59 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 60V tLA4a U 41.4-0vJ5TIZJC-7 0V4 (SO$� w k L.L t Al M L_Ir, 12 Mw tJ 215 -n wvB e va nJ4, ,A z 8- Z Sri z� Type of Building: �' Dwelling No.of Bedrooms 3 Lot Size 45)i3 05 sq.ft. Garbage Grinder(P) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures i .w Design Flow 33 gallons per day. Calculated daily flow gallons. Plan Date 10 19 19 P, Number of sheets Z, Revision Date Title srrf, Arun sf-Prime N s-oz t_AQ.5 Size of Septic Tank /SGO Type of S.A.S. T2�-NGa d2MATioO Description of Soil C7r- C� I-oil wt Y 5i AJO 6"- z 4' L o q,m�l 5 Z 4' 4-? C 54 N D G�(S 1Z0` MribACONZSr A N1� r'x -yh Nature of Repairs or Alterations(Answer when applicable) 2. , (�` 0 �L;A (� s '. r 1 I Date last inspected: j Agreement: E 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 Certifi- Cate of Compliance has been issued by this Bo d o=ealtq. i Sign d $ Date 4 -- —-ApplicationApproved-by- r- . . Application Disapproved for the following reaso i s Permit No. - "' Date Issued —————————.—~ —————————————— T———————— - I THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS w Certificate of Compliance THIS IS TO CE IFY,� at th O -site? Co Se ge Disposal System Constructed(�Repaired (� )Upgraded( ) Abandoned( )by at P a een constructed in accordance with the provisions o Title 5 d the for Disposal System Cons ruction Permit No. �' dated Installer ., d Y 6 igner a 4 , The issuance o thilpe t all no •a construed as a guarantee that the s ge will,function as desi�g ed.�/ Z� Date �(�� I Inspector W ------------------------------- No-7K. - Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS oigpozaf *p5tem Construction Permit Permission is hereby granted to Construct( "')Repair( )Upgrad )Abandon System located at, L o r / C,,pL b C_N,t?pi) (1 0 (. and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this permit. Date: C 1 -1 - Approved by a - C� J - T WN OF BARN LE LOCATION �� ��`� O i , ) • SEWAGE # _ VILLAGEV�C�v,_-pk_�1(�)�_ 11 S ASSESSOR'S MAP_& LOT i.- `136A,i ti INSTALLER'S NAME d P�HON , V 1 i' i I '1 U o 5.- `j > SEPTIC TANK CAPACITY C ti c: LEACHING FAcELrrY: type) + '� 7 �' ' • (size) NO.OF BEDROOMS :� i BUILDER OR OWNER Lft 4� PERMTTDATE: I 12 " t) 'S COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist 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 v L F Vq , , G /�-i I__.-- I ,,--- ,,-I_ " �, , . � I., I I -1 ­ . 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INVERT INVERT o 0 0 00 ' �- 95. 05 _ o EL.= 95.5 � EL.�_.---- EL= 94�8 o w 0� 0 93. 0 (To DE PLACED ON FI" BASE) ' DISTRIBUTION 4' 4' MECHAMCALLY COMPACTED OR 6" OF.STONE BOX 11 Y38 x1' GALLONS TO BE WATER TESTED TRENCH FORMATION ,SEPTIC TANK IF MORE THAN ONE-OUTLET 1 O T ABSORPTION PLACE ON 6 STONE r�►TON O 3/4 TO 1-1/2 SOIL WASHED STONE PROFILE , OF SYSTEM (SA S) SEWAGE DISPOSAL SYSTEM ' NOT TO SCALE NO OBSERVED WATER (1116197) ELEV. =_ 87. 0 ' DIG OUT 5' ALL AROUND TO C3 (66') AND FILL WITH CLEAN SAND PER TITLE FIVE TO ELEVATION 94 I OBSERVATION HOLE 1 ELE'V.__ 98.0' PERCOLATION RATE <2 — MIN./ INCH AT 6 A"-L20INCHES DEPTH HORIZ TEXTURE COLOR OTT. OTHER 0'.-6,, A LOAMY SAND IOYR 3/2 1VONE FRIABLE 6'-24_ B2- LOAMY SAND 10YR 5/6 NONE FRIABLE 24^=42" CI MED/SAND 10Y 7/4 NONE LOOSE 42 — C2 SILT/LOAM 25Y 5/4 NONE FIR,u 66"-120" C3 MED/COARSE/SAND 25Y 6/4 NONE LOOSE _ NO WATER ENCOUNTERED} - GENERAL NOTES SOIL TEST 1) ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO D.E:P. TITLE 5 AND THE TO WN OF _L �TA�LE--- RULES AND REGULATIONS FOR THE SUBSURFACE DISPOSAL OF SEWAGE 2) ONE COVER ON SEPTIC TANK SHALL BE BROUGHT TO P .NUMBER— — 8838 WITHIN 6":° OF FINISHED GRADE, OTHERS WITHIN 12" 3) ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE CAPABLE OF WITHSTANDING H-10 LOADING UNLESS THEY ARE UNDER OR WTHIN' 10 FT. OF DRIVES OR PARKING AREAS H--20 LOADING SHALL BE USED UNDER OR WITHIN 10 FT. OF DRIVES OR PARKING AREAS.. DATE OF SOIL TEST 1/I6%97 SOIL TEST DONE BY CAROLYN J. DOYLE, P.E. WITNESSED .BY: JERRY DUNNING , 4) ANY MASONARY UNITS USED TO BRING COVERS TD GRADE SHALL BE _MORTERED IN PLACE DESIGN CALCULA TIONS. 5) NO DETERMINA TION HAS; BEEN MADE AS TO COMPLIANCE WITH 3 .DEEDED OR ZONING REGULATIONS. OWNER/APPLICANT IS TO, NUMBER OF BEDROOMS . . . . . . OBTAIN SUCH DETERMINATION FROM APPROPRIATE' AUTHORITY. ' GARBAGE DISPOSAL NO TOTAL ESTIMATED FLO W 6) UTILITIES SHO WN ARE APPROXIMATE ONLY, EXCA VA T(ON CONTRACTOR TOP LOAD 5 INFILTRATORS WITH 58 ,� 110__GAL BR. IS TO- CALL DIG= SAFE AT 1-800-322-4844 AT LEAST 72 HOURS 4 ONE SIDES AND ENDS AND ( — / /DAY x 3_-_ BR.) 33o GAL/DAY 1o1y� PRIOR TO COMMENCING WORK *ON SITE I' EFF DEPTH REQUIRED SEPTIC TANK CAPACITY 1500 GAL 1,A.oF M Il X 38 X 1 7) CONTRACTOR IS TO VERIFY GRADES AND ELEVATIONS AS WELL' AS SOIL CLASSIFICA TION . . - . . . . 1 cti SITE CONDITIONS PRIOR TO COMMENCING WORK:ON SITE. DESIGN'PERCOLATION RATE . . . < 2 MIN./IN. � i LIAM 8 PARCEL IS IN FLOOD ZONE ..C» 74 LIEBERMAN y —_--- EFFLUENT LOADING RATE . GAL/DAY/S.F.. 9) LOT IS SHOWN ON ASSESSORS MAP _149 AS PARCEL 130-1 LEACHING CAPACITY AREA X RATE 382 F � ------- J GAL DAY o c, . - CAPACITY . STD � RESERVE LEACHING CAPACITY . 382 GAL/.DAY �SSioNAL E�G '(38X11X 74)f(38+38+11+11 X . 74) JOB NO. 51719