HomeMy WebLinkAbout0226 MISTIC DRIVE - Health 226 Mistic Drive
Marstons Mills P
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL. PRI�ffegtVW
AUG 2 8 2003
TOWN OF BARNSTABLE
HEALTH DEPT.
TITLE 5
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 226 Mystic Drive
_Marston Mills.MA 02648
Owner's Name: Anthony Valenti
Owner's Address: Same
Date of Inspection: August 7, 2003
Name of Inspector: (Please Print) James M. Ford
Company Name: James M. Ford Map:080
Mailing Address: P.O.Box 49 Parcel:011
Osterville,MA 02655-0049
Telephone Number: (S08) 862-0400
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
a Is
Inspector's Signature: Date: August 10, 2003
The system inspector shall su ritapy 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.
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 6/15/2000 page 1
• Page 2 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 226 Mystic Drive
Marston Mills.MA
Owner: Anthony Valenti
Date of Inspection: August 7, 2003
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.
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. System will pass inspection if (with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or 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 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 226 Mystic Drive
Marston Mills. MA
Owner: Anthony Valenti
Date of Inspection: August 7, 2003
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:
I
3
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Page 4 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 226 Mystic Drive
Marston Mills. AM
Owner: Anthony Valenti
Date of Inspection: August 7, 2003
D. System Failure Criteria applicable to all systems:
You must indicate either"yes"or"no"to each of the following for all inspections:
Yes No
✓ 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 '/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—
✓ 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 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.]
No (Yes1No)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 System:
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
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped
Zone I1 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: 226 Mystic Drive
Marston Mills. MA
Owner: Anthony Valenti
Date of Inspection: August 7, 2003
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 S on the site has been determined based on:
rP System(SAS))
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 15.302(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: 226 Mystic Drive
Marston Mills, MA
Owner: Anthony Valenti
Date of Inspection: August 7, 2003
FLOW CONDMONS
RESIDENTIAL
Number of bedrooms(design): S Number of bedrooms(actual): 5
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550
Number of current residents: 2
Does residence have a garbage grinder(yes or no): n/a
Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required]
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings, if available(last 2 years usage(gpd)): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: Currently occupied
COMMERCIAI ANDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no)
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: Pumped 2 years ago-per owner
Was system pumped as part of the inspection(yes or no): 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)
Tight Tank Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Jul. 26185-per as built card
Were sewage odors detected when arriving at the site(yes or no): No
` 6
Page 7 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 226 Mystic Drive
Marsto.ns Mills. MA
Owner: Anthony Valenti
Date of Inspection: August 7, 2003
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: _cast iron 40 PVC other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: 3'6"
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: 1500 gal.
Sludge depth: I"
Distance from top of sludge to bottom of outlet tee or baffle: 30"
Scum thickness: 2"
Distance from top of scum to top of outlet tee or baffle: 8"
Distance from bottom of scurn to bottom of outlet tee or baffle: 12"
How were dimensions determined: Measuring stick
Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
Tees were present The liquid level was even with the outlet invert. There wre no signs ofleakage. Recommend installing risers
on the covers.
GREASE TRAP: None (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.):
7
Page 8 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
0
Property Address: 226 Mystic Drive
Marstons Mills. MA
Owner: Anthony Valenti
Date of Inspection: August 7, 2003
TIGHT or HOLDING TANK: None (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: Qallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: Even
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.):
The D-box was level. No solids were present.
PUMP CHAMBER: None (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.):
1
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: 226 Mystic Drive
Marston Mills, AM
Owner: Anihony Valenti
Date of Inspection: August 7, 2003
SOIL ABSORPTION SYSTEM(SAS): ✓ (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: 20'x 36'-per design plan
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.):
There were no sign offailure from the leach trench. 1 used a camera to conduct the inspection. The bottom to grade was
approximately 9'
CESSPOOLS: None (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 or no):
Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: None (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: 226 Mystic Drive
Marstons Mills.MA
Owner: Anthony Valenti
Date of Inspection: August 7, 2003
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.
B
Front
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3
10
Page 11 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 226 Mvstic Drive
Marston Mills.MA
Owner: Anthony Valenti
Date of Inspection: August 7 2003
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 15 +/- 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: 7184
Observed site(abutting property/observation hole within 150 feet of SAS)
✓ Checked with local Board of Health-explain: topographic and water contours maps
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
_Using the Barnstable topographic map and the Cape Cod Commission water contours map the maps were showing approximately
15'+/-to R round water at this site.
This report has been prepared and the system inspected and passed as of the date of inspection. This report is
not a warranty or guarantee that the system will function properly in the future. There have been no warranties
or guarantees, either expressed,written or implied,relating to the system, the inspection and/or this report.
11
TT WN OFF BARNSTABLE U V
LOCATION �'` M �t{L tJ�- SEWAGE # 0
VILLAGE ✓1• ms i Is ASSESSOR'S MAP & LOT v d" 01>
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY rW�+
LEACHING FACILITY: (type) L. F, (sine) X 3 6
�-- NO.OF BEDROOMS / l
BUILDER OR OWNER /arlf o^ ( -11
PERMTTDATE: 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 acility) S Feet
Furnished by
B
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LOCATION 51WAGE PERMIT NO.
VI✓LLLAGE
INSTALLER'S NAM i AD RESS
e U t L D E R OR OWNER
DATE PERMIT ISSUED
DAT E COMPLIANCE ISSUED_
s
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r; .. ........._.d.. F.Rs...........
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
............rAW!k!...............0 F..........................T. 43G
................
Appliration for Dispas al Works Tontrnrtann rrntit
Application is hereby made for a Permit to Construct (vT or, Repair ( ) an Individual Sewage Disposal
System at:
•--•/Ll/ST/e 7�2i v� M�9IZ.ST..tS M/GGS Lo /3
Location-Address or Lot No.
........ L GjA/T -......_ ..
A. ner Address
W ...........-----•----•-....--................... .............I.....................................
-------___-----------..................------••••-......_..-------••--....--------••-•--......---•
�• Installer Address
UType of Building Size Lot____`�_s__9f?"__._._.__Sq. feet _
Dwelling—No. of Bedrooms...............Z........................Expansion Attic ( ) Garbage Grinder
`4 Other—Type of Building No. of ersons____________________________ Showers —
a YP g ---•----•----------•-•------ P ( ) Cafeteria ( )
P4Other fixtures .................................................................................------------•-------------------------------------------.....__-•----
W Design Flow_____________5'�__......................gallons per person per day. Total daily flow------------- 2a____.._.__-__._._._gallons.
WSeptic Tank—Liquid capacity/4^_0_o_.gallons Length__8.K"___ Width_:I!.'-�"____. Diameter________________ Depth.-f_A"'__.
x Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area...................sq. ft.
3 Seepage Pit No--------/---------- Diameter.....14- -__- Depth below inlet___3:5....... Total leaching area__3o 7__E.sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed ........if ........... Date.`T�� .__ /�8�
Y
1-1
Test Pit No. 1__L_.Z.___minutes per inch Depth of Test Pit... Depth to ground water........................
44 Test Pit No. 2_i5�.L___._minutes per inch Depth of Test Pit... Depth to ground water..........
04 ---•-••--•-•-•._..-•••••-•••-••••....................•---------.....-----------...._•-------......-•........................................................
0
xDescription of Soil.... 30"-144" Co SAri�Dp -------••--•---_---•-
(� ••••••••-•-•-•----•......-••---••-••••---•---...•-•.....-••--------------•--•-••••••--........................•---•-------•------•--•-----•••••••.__.................................................
W
V Nature of Repairs or Alterations—Answer when applicable...............................................................................................
•-----------------------------------•-------------------------------------------------....---•--•---••-•--••...•••••••--•------------------•----------•---------•----------------------•-•••-•----•-•--
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITL U 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a ertificate of Com ance has been •ss a oar ea
Signed... l = . ........... - 4_0.:_----
Date
ApplicationPPr ---•........................................................................•-
Date
Application Disapproved r the following reasons:..............................................................................................................
,r
•----...-•----•-------•--•------------------•----•---•-•--•••••.._..__._..•----------•••-•------•••-----•-•------•••-
Date
Permit No.__)71-1 7d --•--..._...... IssuedL.......................................................
_ ` - Dale
7el
--------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........... .............._OF...6110NI............................
_ ..............................................
Appliration for Disposal Morks Tonstrudion "umit
Lppliltion is hereby made for a Permit to Construct (4—) or Repair ( an Individual Sel`��'I�� 'Disposal
System at:
Z c,7- l
................................................... ................................................ -----------------------------------------
Location-Address or Lot Nd;
.................................... ..................................................................................................
Owner Address
....... .........
Installer Address
Type of Building Size .............Sq. feet 41-
Dwelling—No. of Bedrooms..............iK.........................Expansion Attic Garbage Grinder
Other—Type of Building ............................ No. of persons.................�:.......7, Showers Cafeteria
Otherfixtures ......................................................................................................................................................
Design�Flow..............5. `______.______________._gallons per person per day. Total daily flow........... ....................gallons.
M Septic Tank,—, Liquid*capacity,14T-ae...gallons Length.A.14........ Width:!L4'_..... Diameter-------_------- Depthtf ......
Disposal IV66611 No_ ____________________ Width___.._..____________ Total Length.._________________. Total leaching area....................sq. ft.
> Seepage Pit No.......Z........... Diameter----/ ......... Depth below inlet__:?:_._.___. Total leaching area.3�1-._jLsq. ft.
Z Other Distribution box Dosing tank.,(
0.4 Percolation Test Results Performed loi
1.4 -.1.........- ------- ............ .........
Test Pit No. 1_4t---Z-------minutes per inch- Depth of Test Pit..2_�<'......... Depth to ground water_______................
Test Pit No. 2.!�-'___.?......minutes per inch Depth of,Test Pit._...44------- Depth to ground water........................
...........................................................................................................................................................
0 Description of Soil--. ..................................................................ZP.................................................
.......................................................................................................................................................................................................
U
W - -
----------------------------------------------------------------------------------:.....................................................................................................................
U Nature of Repairs or Alterations—Answer when applicable------------------------------------------------------------------------------------------------
...................................................................................................:....................................................................................................
Agreement:
The undersigned agrees to instalj:*#e aforedescribed Individual Sewage Disposal System in accordance with
/the provisions of TIME 5 of the State Sanitary Code,�,wThe undersigned furthe r agEpes not to place the system in
operation until a ertificate of Compliance has been j§s fTie oar ea h
Signed.'. ... .... ... . ........... .......
Date
Application ppr ... ........ ...ri
........................................
Date
Application Disapproved or the following reasons:..............(......................
... ................... ..............................................
4.1......................................................................... ................................... . .............................................
Date
Permit No.Y1-1 7
........d
...................... .............. Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
'OF................................................. .................TO rtifiratr of Tompliattrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (i-,) or Repaired,
by-----------------------........................................................................................................................................................................
at........ ..... ..............g��'/j/'/(- <'I /V f f Installer 14;e, 1�elj%ej
--------------------------------------------------------------------------------------------------------------------------------------------------
has been installed in accordance witli the provisions of TITLE 5 of The State Sanitary Code as descr' ed J.477
ilxe-
74
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application for Disposal Works Construction Permit No.__. .... .................... dated------ --------------- .................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUPCTION SATISFACTORY.
DATE... - Vi----------------------------------- Inspector................ ....... . ........ . ...................
---------- 7,,
THE COMMONWEALTH OF MASSACHU TTS
BOARD di:�,.'WEALTH
ran iSTi9e—
.....................................0 F......................................I.............................................
No...
FEE........................
Disposal r % cati
on Prrutit
Permissionis hereby granted.............It... .....................r......................................................................................
to Construct 0,< or Re air an Individual SeAFe Dis
at No.................. yj dlM W��,Vly -
...................................................................................
Street ........**-------------------1'je-----
as shownon the application for Disposal Works Construction Permit No________
--- ........ Dated._______-..._._ --------------------------
.................................. .......
-- ------ i---- ... ......
Board o Health
j
DATE............. 0
................................................
FORM 1255 A. M. SULKIN, INC.. BOSTON
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1 MIN. U G tOR EQUIV.)
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PIPE-MIN.
, PITCH 1/4 PER.FT. . < _
_ - LoT �'/4 h t� PITCH I/4°PER. tt LEACHING FI y47
a ., I ,� G ELD t.�,RE'i7UtRED)
4 , t/9 -I/Z WASHED STONE 40
o P � �M �'• INVgT
� WASHED
SEPTIC TANK IN ? DIS7 INVERT ,, «STONE ..
INVERT Et 48. � •PSl�C 3/4 -L1/2 6
ti ��; f ,a- '�B �B !'.Saa• GAL. INV BUX
.�, a. EL......... .... / tNVERT mac.4?37
4 - EL. �3. _ INVERT
41-to
�' S � 4. ,� ��' �, :•;r, � - PROFILE OF. .���►
v. i GROUND WATER TABLE ivo v�
tillSEWAGE DISPOSAL
' \ / _ SOIL LOG SYSTEM TYPICAL CROSS SECTION
NO SCALE
DATE J'.�c LEACHING FIELD
NO SCALE
I b S I TEST HOLE I TEST HOLE 2
ELEV. . . . .. , . DESIGN DATA
FLev. . . . . . . .
Tt"sT ..
k act= Z FZ
12`MIN. - ,
v NUMBER -0F BEDROOMS 4 WASHED `3.47
r LET r �xmp -sop
L + ., TOTAL ESTIMATED FLOW ' , 47 rim!
. .. GALLONS/DAY801 "OM LEACHING AREA Z4 4RFO
u �_.-.._ _.:._ _... oQaposea < , , i �, .5•�'.30 , .-, SO-FT./TRENCH
/TRENCH ST1G PI -
ti
Gf.no g I 1 # SIDE LEACHING AREA
J �ti l SQ.FT./TRENCH L3/4
a p ±
¢' A72de GARBAGE DISPOSAL . ,y�. . ..(50% AREA INCREASE)
\ S,gT•p S WASHED
•, dMrh STONE
L ^r1/ s+ec� TOTAL LEACHING AREA 7ZD
3� v ' ✓ d . PERCOLATION RATE -�', .77 C ep TJ�/o PER. INCH
Zo •
LEACHING AREA PER, PERCOLATION RA 7Z91
r'��� � „. t-•-""'. ..'.. : Ti4e/,IC. _ - QdTTAs•1 GF.�f�✓�7i ffIf
- - t1' / 144 a 4 r Zv GROUND wArER o _t ! I .9Z. / /4¢ 4�Z,''4£s AP-ROVED
�. _.. . . . . : . . .': . . . . .. BOARD OF HEALTH �-wco. rrr�-.-�'r�
... . . r.WATER ENCOUNTERED OAT
WITNESSED BY
AGENT OR INSPECTOR
BOARD OF HEALTH � z H
Ay
oTvG ENGINEER �O
.
PETITIONER '
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