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Home My WebLink About1199 OST.-W.BARN. RD - Health 1199 OST.-W.BARN� Marstons Mills A = 125 — 039 a fl la,5 -03 9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments z '( 1199 Ost. W-Barn Rdq 4d,��" Property Address I7) Lesinski Owner Owner's Name information is MM required for every Barnpdble Ma 6/8/17 � page. City own State Zip Code Date of Inspection t� 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 A. General Information filling out forms on the computer, 1 G use only the tab 1. Inspector: key to move your cursor-do not Chad Hathaway use the return key. Name of Inspector H.P.S. �y Company Name P.O.Box 151 Company Address Forestdale Ma 02644 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 6-8-17 Inspector' a Date The syst m inspector shall mit a co y of this inspection report to the Approving Authority(Board of Health or Spector within days of mpleting this inspection. If the system is a shared system or has a design flow of 10,0 r 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 Form:Subsurface Sewage Disposal System•Page 1 of 17 ,Co �S Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 1199 Ost. W-Barn Rd Property Address Lesinski Owner Owner's Name information is required for every Barnstable Ma 6/8/17 page. Cltyrrown 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: tank in good cond. Tank waas pumped at inspection for maint. purposes. Dbox and pit camera inspected Dbox no visable cracks or leaks. Leach pit has 12"of reserve cap. from high water line to bottom of invert. No staining above current level to indicate past failure 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 M 1199 Ost. W-Barn Rd Property Address Lesinski Owner Owner's Name information is required for every Barnstable Ma 6/8/17 page. City/Town 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 M 1199 Ost. W-Bam Rd Property Address Lesinski Owner Owner's Name information is required for every Barnstable Ma 6/8/17 page. City/Town 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 ❑ ® 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 1/day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1199 Ost. W-Barn Rd Property Address Lesinski Owner Owners Name information is required for every Barnstable Ma 6/8/17 page. City/Town 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 9P 000 d. ❑ ® 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 1199 Ost.W-Barn Rd Property Address Lesinski Owner Owners Name information is required for every Barnstable Ma 6/8/17 page. Citylrown State Zip Code Date of in 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•3113 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 1199 Ost. W-Barn Rd Property Address Lesinski Owner Owner s Name information is required for every Barnstable Ma 6/8/17 page. CitylTown 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 information in this report.) ❑ Yes ® No 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 1199 Ost. W-Barn Rd Property Address Lesinski Owner Owner's Name is required for every Barnstable Ma 6/8/17 page. City/Town 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: pumped 2 years ago Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1000 gallons How was quantity pumped determined? tank size Reason for pumping: maint. 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 M , 1199 Ost. W-Barn Rd Property Address Lesinski Owner Owner's Narhe information is required for every Barnstable Ma 6/8/17 page. CltylTown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1986 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2'4" feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: 20 feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 2' feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) PVC tees in place If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gal Sludge depth: 3" t5ins 3113 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 , 1199 Ost. W-Barn Rd Property Address Lesinski Owner Owner's Name information is required for every Barnstable Ma page. Cltylrown State Zip Code Date ate of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 31" Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 4" 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.): tank was pumped at inspection as a request by homeowner for maint. only. It is reccomended that the holding be pumped eve 2-3 years under normal use to protect leaching Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene El 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 MARME Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1199 Ost. W-Bam Rd Property Address Lesinski Owner Owner's Name information is required for every Barnstable Ma page. Citylrown 6/8/17 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.): baffle in place no concrete decay 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 El 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-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Y o unta ry Assessments M , 1199 Ost.W-Barn Rd Property Address Lesinski Owner Owner's Name information is required for every Barnstable Ma 6/8/17 page. Cltyfrown 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.): Dbox has no visable leaks or cracks 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: 6' Leach pit has 12"of reserve from existing high water stain and bottom of invert. No staining abovecurrent level to indicate past failure 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 , 1199 Ost.W-Barn Rd Property Address Lesinski Owner Owner's Name information is required for every Barnstable Ma 6/8/17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ 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.): 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1199 Ost. W-Barn Rd Property Address Lesinski Owne.- Owner's Name information is required for every Barnstable Ma 6/8/17 page. Clty/Town 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1199 Ost. W-Barn Rd Property Address Lesinski Owner Owner's Name information is required for every Barnstable Ma 6/8/17 page. Cityrrown 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 I ^ l (O G t5ins•3/13 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1199 Ost. W-Barn Rd Property Address Lesinski Owner Owner's Name information is required for every Barnstable Ma 6/8/17 page. Cltyrrown 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: 20+ 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 on barnstable website You must describe how you established the high ground water elevation: lot el. 59-60 low el. in area 39.2 Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Disposal Sewage Dis 9 p System•Page 16 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1199 Ost. W-Barn Rd Property Address Lesinski Owner Owner's Name information is required for every Barnstable Ma 6/8/17 page. Cityrrown 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 I i t5ins.•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 17 of 17 ASSESSORS MAP NO: b t NO.: �3� _ S Z � PARCEL o� F:311......................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �/ ✓/ a� �.0(:�// oF...... !P/V.ST�.BL ............... ........ q� O or Dig u 'n� ( � ,��Itrttttlan � � � 1 urk� C�nn.��r�tr#t n prntt� Application is hereby made for a Permit to Construct (V� or Repair ( ) an Individual Sewage Disposal System at: . ?�:...1�_..Q :T:.1)--:.66Jiit/STt18� �-D_ ....rl�. tTDs-- ?/Ll s.................. --•--- ocati n- ddress or LotNo. ter+ Own � Address v ----•-!� /.5 CQL ........ .............................................Ad.......... Installer Address d y� ,e Type of Building Size Lot......... . ........6...Sq. feet U Dwelling—No. of Bedrooms................:..............__..__Expansion Attic ( ) Garbage Grinder ( ) pk Other—T e of Buildin WCP a 64Am4&. No. of persons............................ Showers a Other—Type g --- -------------------------------------- ..._ ( ) — Cafeteria ( ) dOther fixtures ----------------- ------•-----------------. ----------------•---•---------------------•--.....----- ------. W Design Flow..........................:5s5..........gallons per person per day. Total daily flow.................. ...............gallons. WSeptic Tank—Liquid capacity_000..gallons Length-----%Q.1. Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area...zA.(LY....sq. ft. Seepage Pit No.................... Diameter......... ./.... Depth below inlet.................... Total leaching area._�?.6.-`/.._sq. ft. Z Other Distribution box ( ) Dosing tank ( ) `4 Percolation Test Results Performed by.............................................. --------....... Date----------------•---......_--•---....... 14 04 Test Pit No. 1......A.....minutes per inch Depth of Test Pit...... . .... Depth to ground water........................ f= Test Pit No. 2....... .....minutes per inch Depth of Test Pit.......C_. _!.... Depth to ground water.__N.'!.'.......... Rir ----- ------------------------------------------------------------------------------------------••----.-`.------._. .--.-•-------•------•-----------•----- 0 Description of Soil...Q.:.y-----..2eS�/L �- 5Uf5c/4- "<S6me CLAY " Y /� 'V' o. T P ..-----••------•------------------------------• ......----•-•---------------•-•. ..................................................... -----------------------------------------------------------------------------------------------------------------------------------------------------------------•-------------------------••--•-••----- VNature of Repairs or Alterations—Answer when applicable................................................................................................ -----------------------------------------•------------------------......------------......----••-----•----•-------------------------------------------------------------------.....----•---•--••-••---- Agreement: The undersigned agrees�o install t aforedescribed Individual Sewage Disposal System.in accordance with the provisions of iI'L IE 5 of the St anitary Code—.The undersigned further agrees not to place the system in operation until erti of Com cc has been issued by the board of health. Signed_.. .......-D I,............... Date >(j 11 - 1Z PPlication Approved By................................................... - Date ... � Date Application Disapproved for the following reasons:.............................................................................................................. ---------------------•-........--•------.............-----.................-----------I------------......--------•..........----.....------------•------------------------------------------•------•---. Date PermitNo......................................................... Issued....................................................... 1i Date i ... 3 9 No................ .... t THE COMMONWEALTH OF MASSACHUSETTS BOARD f OF`.,HEALTH 6Ff...:. J. �`tJ � 3-ta��-------------------------- Appikaiion for."Disposa iks: Tonstrtution Errant Application is hereby made fora Permit.,,to Construct ( or Repair ( ) an Individual Sewage Disposal System at L 1 .. ... [f ......l.. or lJ I�1 - • �j �L./v Own .... - --..•Address ; a �:�:....... lC�5 cQt e ..:. ..........:... ..............•----.............---... ;res'---•-------- ..:--------------_.....------ p� Installer Address �tb ,7�/ UType of Building Size Lot....__.._...................Sq. feet �-, Dwelling—No. of Bedrooms...............c........__.._....`.....Expansion.Attic ( . ) Garbage Grinder ( ) Other—Type of Building ��b..��'�'.�•-__. No. of persons................................ Showers ( ) — Cafeteria ( ) W Other fixtures -•----------------------------------••-•--••----- Design Flow........................�� ..........,:.gallons per person per day. Total daily flow.................... ......._......gallons. Septic Tank—Liquid capacity..�404-.gallons Length.....h` .".. Width................ Diameter...... ........ Depth................ x Disposal Trench—No. .................... Width.-:....y........... Total Length.................... Total leaching area__.4, v'...sq. ft' 3 Seepage Pit No...........1........ Diameter.........6....:.. Depth below inlet................... Total leaching area-.' .. ..sq. ft. Z Other Distribution box ( ) Dosing tank (. ) 1--1 Percolation Test Results Performed by................................................. . : ....................: Date---...------•--•------- ------- a Test Pit No. L._... *.__:.minutes per inch Depth of Test Pit....... ...... Depth to ground water......................... 44 Test Pit No. 2......:...:.....minutes per inch, Depth of Test Pit:__.... :._.. Depth to ground water...AIA-Ve...... x :...... = .... O Description of Soil ..eI.�... r . _'�- ...... - ' !9>u'�_.... �D.�1 :---� �� ........... ......,�Oc.�......-- cu ? s , ----------------------- W UNature of Repairs or Alterations—Answer when applicable...............................................................................•...................... ..---•-------------------------------•-•----••-----------•-•----•-••-•----.................--•----•------.......... Agreement: The undersigned agrees tq install t aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE. 5 of the St nitary Code—.The undersigned further agrees not to place the system in peration until erte of Com a has been issued b the board of health. Signed..../••.'.......--•={...... ............................................ ......'......-.. Dam v pplication Approved By •--•--..........1---------------------. ............................. Date Application Disapproved for the following reasons:...........................................................................................................---- --•------•--•-•-•---•-••••-•-•--•----•........----••••--••.............•-.......:-----............_...._.....---•-•-•-------•--......•--•--•--•--------••••-•......---••-----•-••-•-----.... ...•_....._ Date PermitNo...................................................----- Issued......................................................_ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF 434)�W_S7413411= .................................................... Tatifirat a of Toutplittnrr TxS I TO CERTIFY, That the Individuals Sewage Disposal System constructed ( 4 or Repaired ( ) v' 13k'/5 C GEC,. at... Q ..._. ... ...t '.. ----•---...---•---------•--•------------------------------------------------/...............................................................- has been installed in accordance with the provisions of TITLE 5-of The State Sanitary Code as described in the application for Disposal Works Construction Permit No..................................L...�.....f... _......._....... dated...... .... .... ....................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCT 01 N ATISFACTORY. DATE................... . : ..1.. .L= ......--••--•.............. ...... Inspector.................................................................................... ALL vNSjt Aa .,C ?'AA •lt:tZ,At. THE"COMMONWEALTH OF MASSACHUSETTS et,� �,� t v { { I�v SIT P,_f. f—e BOARD OF HEALTH �"`° �`� 1"T i' 1 %U two✓ Agee' , f1f81- ? F ��coV�► t lz c No....�.�..-..l.Z!(� ............................ .........OF..................... ..... ........................ FsE... .....: ...L,c �i� outtl ork� �onufrttr#ion rruti�� Permission igrantedLs QL s hereby ... ... --•--•................•........_................_......... .................. to Construct 00or Repair ( ) an Individual Sewage Di s oral System l lwligs b T at No.. Q _.....(v......_US E .. L. ... R jC ................ ! :..................................16...... .... /LLS......... Street S 6— /L 10 as shown on the application for Disposal Works Construction Permit N(o..................... Dated. �.�...�._j.t.!.. ��<) • DATE.......... - Board of Health �s_"!'",-................................:. FORM 1255 A. M. SULKIN, INC., BOSTON l Z. z - d 44. IV 3 3 r �v 1 30 lo, 1 � 9 .0 24 itmcA� j \ m ` yf►GII t W \ Ttr-J I / I r III 10070 :55 -�1 ik'z :01 QXlz' a1 i 04 rt Al S 74 �- ASSvH� C m�- P�'oT,E-G.T orI I CERTIFY THAT THE PROPOSED BUILDING SHOWN ON THIS PLAN CONFORMS TO THE---- ZONING LAWS OF L40L574 2 -E , MA. LEGEND DATES Ab Z' fro EXISTING SPOT ELEVATION 06 �. p PROPOSED SPOT ELEVATION EXISTING CONTOUR ---0— —— PROPOSED CONTOUR 0 j�. ° '�� ;✓!`� P \'2:' �° PAUL A. y� Z LEVY i NOTE: THE LOCATION OF ANY UNDERGROUND SEWERAGE,WELLS, OR OTHER UTILITIES SHOWN ON •`''=;, �,�N,.331 �' No. I0617 y THIS PLAN IS APPROXIMATE ONLY AS DETERMINED o FROM RECORDS AND/OR VERBAL INFORMATION. >,R' THE CONTRACTOR IS RESPONSIBLE FOR THE `'y VERIFICATION OF THE EXISTING LOCATIONS IN THE FIELD. RM I STERED ENGINEER EEO R R FENGINEERS 8c ELDREDGE ASSOCIATES,INC. ,� p ®p®SEQ PL®T LANCLIENT, -.dam— LANDSCAPE ARCHITECTS JOB NO. �� Lp%(o Q5T15RUIZL4Z- W. 86RA)Sj.—u6 .PLANNERS — LAND SURVEYORS DR. BY: IN 889 WEST MAIN STREET CHKD.BY=_� B��Pti1ST8�. � M�55. CENTERVILLE, MA. 02632 SHEET. I OF SCALE: DATE: { p�JL L�".f� . $L"r�'-.'9e5�id°�afldC?vlYJhar.. �;�"�"a�' ;&ifl+�LR.1rr`h,,.i?f7.:a+:a.,...;Yi1'ei:u�' :A:S_,tda'.,h;YCiV::F234E,:3�5'`.xW2.ae'uaa�a�floS,ww>n.a,.-see.ami.cmx+i�:..;.,,:.:axaieaa.a..cueac�,e•.H. /Y07"E TNF'_5_-7 TANk OR ~ LEACH/NG P/T ARE MORE TNAJV /a"SE40-W,� GRADE, At 24'O/A M E 7'.ER CoNC.P.F"7-.= CO PIER �— SCHEAULE ,p0 SJNALL BE OR006Al7- T® G,TA D.E.CAN EXTRA CDNCRL"TE OV.C. P/,PE tr F,4Yy CA ST /RO/Y CoV-FT S YALL B.E I/SEO c�• /00. D �'OVERS M/N. P/TCN /F/N OR/VEN/A Y - 2 i�r /+C�N. C4NCR�TE =d �y Co }iER CLEAN SAND A • UQU/D LEYEL I6' $CN£IA Y1 2 -AYE R l I� PY.G P/PE • o.o o• /+9/N. PITcN Oa Gi4L. ' d t • . . • . • 1 ► e •4 DIST. yy�?SNL=D S?O/YE SePT/C TA/VX • . . / / • 6aX o r o • t � • • • • • � .'o •• • •+�:'• . � D t • eEF%ECT/Vg 1 r s y 3 4 — I �2 • ' 1 i • DL PrtJ ' • 1 ' • , WA51YED STOlVE t /S/x ?• 5 = 377.5 GPD 1 •Q 1 t ' • • ' e e ' - p,QcCAST SEEOAGE �•. D n 1 1,3 x ) ,p = 1,13.0 6Tr�D ► v. < 1 • s • t • e / 1 p ••y y a ► Q / e • • • of 1 ' a o P/7 DR EQU/V. -PI T C-4PAC ITI D• 5 crpr3 • n A x S,�I /NYERT AT EUtL PIM& 1w, d FT. /NL F7' .SEF'T/C T.41VK S 0 Fr, _ � F7: D/11 M. TstBULATION� OCJ?'LET SEP7'/C TAN/•t 9y 8 Fr. _ //VL.ET 40/57I?/.817/0N BOX W0 FT. SECT/aN OF GROUND N!�4TEfP 7,4BLE OU7-LETDI57R'/e3JT/O/d Box93•, F7 /NL�-T 4-=ACNING >/T `/z• FT .SEd�V.�lC�L� L�/S�4�S°A 1. SS�dS� , 1y9 7;q5 ✓,GAT!®id L AEA CH/NG All/T _ DA6516/V CRI TER./� SCALE '01,4fzN5/I0 14 40 -Fy NG/,�Ic�Er? OF BEl�ROQI+9S DIAIENSION G_I-FT. G,A,-0AGE D/SPOSA L" (/iYIT SO/L LOG TOTA/. ES?1N9.4TED FLOW 330 0.44.1DAY . SO/L TEST */ SOIL N✓,1,3, R C,' 4--ACHIM5 P/TS / f^ELEY. �6 70 EL�i! '(�, �O ,DATE OF SG7/L, TEST S/L�y L SAC h'ING PER P/T f�.SI SQ, FT. 9 i 'r' Tcf-`-r'L R�SULTS hl1TM�SSFD laf'LV -'� BOT7"01-f 4—S41,Ct/JNG P-m P1r—AZ _SQ. PT !.4` c''-,. �:^!L �r.. �,>•�_:�, �_ Pt/YC44AT//JN /@r?Y��! ^ . 2 M/N�/NCH TV r,9L LFACN/NG �.?EA '�. SQ• FT, 5 �:•,c GG/' `! -�` �;,�- �L� '! 1�=��:c�ULA7''/OP/ R.-ate::—= --- Q;}.5.e%E L C4Ci1/N6 AR,f °+ 2 4, S4. FT. ` .I2� 4 % �'�'• �� .•, e +5�� y l i T . 7-'J' /«�c Ci.r DW �_• C3`11L �� ?td No.31115 — >''= LEVY & ELDREDGE ASSOCIATES INC. r\�S �• "~"� ?4 /o 53' /n. 889 EST MAIN STREET CENTERVILLE.MASSACHUSETTS 02632 rc� NDGRDUNA yvi4TFR FNCov�vrEeEo CLI,FV7- G/e0 UiYL7 ,WA TER AT � t� —�wvvn►7 IIU1r IYU: Z n" PARCEL N -0.. S [ THE COMMONWEALTH OF MASSACHUSETTS R `� BOARD OF HEALTH �G a : ' OCUI✓.....OF.......1°J !P/1J.ST -BLS------------------ ...... J qq ; �I�'�`5Applirativn for Diapasaf arks Ton,otrartion 1hrmi# Application is hereby made for a Permit to Construct (y� or Repair ( ) an Individual Sewage Disposal, System at: 1..:.:BfjiPNsTf18 � ,PD- ' 5To'vs......... LL!5............................. ---------------- W ocati n- ddress rLDAa , ....... .... - G..........._ ...... ..P.: Q:._.2� .. %�!� iv�� ._ --•- Own Address a .............................7)91: �Qz L........................................ .---•---------•--•-.........----•-•----•_-- - .....__. Iostallei Address d �� Type of Building Size ...Sq. feet U Dwelling—No. of Bedrooms...............c; ..........................Expansion Attic ( ) Garbage Grinder ( ) a'4 Other—T e of Building w417 fR�tmE. No. of persons............................ Showers YP g --- -------- - -------•---•-------•---•• --�- ( ) — Cafeteria ( ) Other fixtures .-----------•---••---•• ••---••--•--•... Design Flow......................... ...�.__..___..gallons per person per day. Total daily,flow_.._......._.._..33�1_...............gallons. Septic Tank—Liquid capacity.00a..gallons Length-----/Q.". Width................ Diameter.___.__.____•._. Dept h................ W ...... Width:..................• Total Length Total leaching area..__,A.k?.`l.._.s ft. x Disposal Trench—No. .............. g g q, Seepage Pit No.....__._.�__._..... Diameter.._......b./ `.... Depth below inlet.................... Total leaching area._a..h.__l...sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed b .. ........................................ ............ Date........................................ Test Pit No. l....... .___.minutes per inch Depth of Test Pit......�F....... Depth to ground water_. tX Test Pit No. 2______ __...minutes per inch Depth of Test Pit....... Depth to ground water...N.'....E.__. a -•--------------•--------_--_------------•-•-----_-_--_-______----•--•--•-------•----•---•---------•-•-----...............------•--•--•---------.... D Description of Soil...0. y..------otP 5d/L-S Uf��L S eMjE c c f�y ........................................— /.... ......... (xj IN i✓A - G�1' c._... '___fI-.✓..LF--L----- N4 P�'E'O�l�v➢J 14!!g.T_ .. W UNature of Repairs or Alterations—Answer when applicable............................................................:.................................. --------------------------------------•--------•--------•-•---------•--------...-...-----•--------•----------•----------------------------•---------•-•-----------....----------------..._•-•-_--•__•-. Agreement: The undersigned agrees_o install t aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the St anitary Code—.The undersigned further agrees not to place the system in operation until ertifc t of Com ce has been issued by the board of health. Signed.../-.... ------ � D�_ Date hcation Approved B Date Application Disapproved for the following reasons----------------•--.......--•--------•------------••----------••-•-----------•-------...-._......_._......_..__ ......---•-••-------•---••--••--------------------------------------------------••----•-.....----._......._....--•-----------------•---.....----------------------••------••-•-•••---•.......--••-------- Date PermitNo....................•--•--....__--------•••-----_.. Issued------.........----- ! ..... Date --------------•---•-••--•-•--- THE COMMONWEALTH OF'MASSACHUSETTS BOARD OF HEALTH pUl/.c/ 419X 1L1 S74,6 L = ..........................O F........................................................................... ..... (In if iratr laf (lnmplianrr TH IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired by....... �1._..11 JE'lS C U CL•----•---•.........................•-•-•_•---•-- ---•-------•---......._.....---....---_-_.................-•-•-............. .... (...)..... at LQ.T.. �?......QSjEJJ✓LL,6 ` A4 6t9A ar/78L,5 AD T4)A/S n1IL1S _.. .. -----•--------------•------•----------------•---_ -,........•-- ••---•--------.....----- -_-......----..._... has been installed in accordance with the provisions of TITLE -5•of The State Sanitary Code as described in the application for Disposal Works Construction Permit No------ ........ dated....._ ... ............... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUA ANTEE THAT THE SYSTEM WILL FUNCT OJ N bbATISFACTORY. DATE .. : ..1 ................................. Inspector............................:....................................................... THr COMMONWEALTH OF MASSACHUSETTSv s .T P E G v BOARD OF HEALTH <""`"Lk ca``�JlI J f^"i' -7GJ.I.Ui✓ r7jeN 5 r1-9 ' FF b V c u�►I t No.... �. ..-..1.? 1 (' ...........................................OF.....................................!�LE............��........—�- 1- - --I z. FEE........................ Disposal Works Tanstrurtiun rrrmif , Permission is hereby granted....._:..`/:. �/SCQLL to Construct ( I)"or Repair ( ) an Individual.......... Sewa a Dis oral S stem 1 1 F T r.I _-__-____---~--' a at No..4197......(._...._G STEM'-✓_/LL � - [aJ� t3r7,lZN�T/9 LO r�D� I1'I�j•A'S T�}!c/S /�'J IL Le ...._... ..... --••................ .... ................ ......... Street F as shown on the application for Disposal Works Construction Permit No...................... Dated.. ._._...�_�_...�_:.. r.::: t._�ts,,,1 } .. .................. -•-•- r- Board of Health DATE.......... ............... ...... FORM 1255 A. M. SULKIN, INC., BOSTON 1 r t S � � =6, /•-} �, � . F- � LOTS S,Y \ \ Zo►�E RF \ 1 c1 /4 _ 3,56 9 A � I ioo.o Ima(p ° IF R n� �0 Re5rkly /a , , I fir N L Ea�11 / I \ / L : -/ LJ,cs i 4 rc CIS i t`+ I CERTIFY THAT THE PROPOSED BUILDING SHOWN ON THIS PLAN CONFORMS TO THE- ZONING LAWS OF 941M'7,4 Z--,l , MA. LEGEND DATES EXISTING SPOT ELEVATION 0 PROPOSED SPOT ELEVATION EXISTING CONTOUR ---0— —— ;" ,.� D.'''r!C) P. C`G PROPOSED CONTOUR 0 ', / PAUL A. NOTE: THE LOCATION OF ANY UNDERGROUND o ,,,� SEWERAGE WELLS OR OTHER UTILITIES SHOWN ONNo. LEVY r: No. IOG17, THIS PLANTS APPROXIMATE ONLY AS DETERMINED �'' �� FROM RECORDS AND/OR VERBAL INFORMATION. >. ... •';_'` -' �� `� �.\i FR�',o� THE CONTRACTOR IS RESPONSIBLE FOR THE R � VERIFICATION OF THE EXISTING LOCATIONS IN THE FIELD. AkjAlw REG I T ED NGINEER BE91211R=RD LEVY SC ELDREDGE ASSOCIATES,INC. CLIENT PROPOSED PL T 1 Am ENGINEERS - LANDSCAPE ARCHITECTS JOB NO. LoT� osT�,�vI�c�- IU. 8,q,enlsT,q.r3uy .PLANNERS - LAND SURVEYORS DR. BY= 2-4� IN ,eoq.d 889 WEST MAIN. STREET CHKD.BY:.IL' 1_ 9,4R IJ.57-,+B 4 CENTERVILLE, MA. 02632 SHEET.LOF ? SCALE,_ DATE= / /� 8� /V07e /F E/TN,--R THESEPTIG TAoV,n< p,qV L2'ACH/ivG P/T ARE MORE TNAIV /2"SELOiV IO FT W/A/• 4'D/.4. GRADF, ,A P4'O/AME'7ER COIVC.P,C--7-= COYZR� +0 SWA L L BE I3 R 0 uG Al? To G,TA D.=.cA N FX7RA CONCRETE OV.cP C HEAVY CA S'7 /RO/Y C0V�� S/�,�L-L BE USEd �c :DO. D CDYERS M/N. P/TGH /F/N OR/VEyt/Ay f - 2 •��•'' ^1/N. C4NcR�TE C} CO F,ER CLEAN._, N d� SCN£-o ULS ace_ _ _ 2�LAYrR Y.C. 1 - r o c i o a 3 oo o GAG. • 1 • • . • e • e o OF Vb I8' %4 PEA T SEPTIC TAAlX Dl ST, •'4 1 • o , • • . 1 r , 0 4 WA 511PCl STONE :' BOX o t o • 1 q B • • • • Ir' .°• � .. r 1 1 eE�/"ECT/VLF r` * • y 3l4 - �2 • ° ° ri • pFP7rN • • 1 ' ao WA5.t/EpS7'jONE ':pro �•o� 11 • • • • r I —�G v 1!?x 1 .O = //.3.0 !TPD ► a. , r • • • • • • . r p ••P — P.4cCA.ST SEEPAGE /!+/k/Ar'TT &r,LEVA7-1DNS o ► o r r • o • r r e o P/7.OR EQU/V. 71TCAPA<�Ty' o, 5 fT�D /N%eRT AT ffJILDING T. !NL FT SEPTIC Ti4NY� S G FT, FT O/fl fy7. C(SF Ti48ULAT10N> OUTLET SEF'T/C TANK —FT° /N,.E7"D/57RI4117710H BOX Wo FT. GROUND W,47-ER L. TX& E SECT/ON o F' • OUTLETD/_sTR/,ogrloN e�oX93• F7 /NL E r L.EA r i!/NG f>/T '1_ L,7 FT �^a��VA GE A0I S IC'O SA L. .� LEACH1 V45; !0/T 7A -11-A"TIDN DES/GN C917ERIA SCALE : %s" _ /,- 0- A_4FT. ,o1,4fZNSJa14 A FT. NU,�l6ER OF BF.DROOA9S .3 DI�'iE7d�I0N G_�FT. G� u�=Eo/sPo sAL r�NIT�/a_,vF SOIL LOG _ TaIAL E37/M.4TED )-Y_o!N 3,?co G,4L.1DAY SO/L TEST Al SO/L TEST#,a SOIL ?p�ST NW-13z'R OF Z--ACN<NG Cl/7- I / 70 7 '7 !^FLLcY. ELF!! �r. O DATE OF SOIL TEST S/O-E Z-e AC-�l/,A/c, PER P/T 457 SQ, FT. I� ? �)'NA.rJ�.,' L „N� a a rTo.�L ti° h'lNG pg R P/r - —SQ, F7 TU r4L LF:•1 C/•N/NG A,QEA :-.;:� � rl � :~- c� •! pE,A:°COt.A'r/oN R.-3;'=�L2 — MIN. !INCH C.I'%ELEACN/ti'G,q 4' A t SQ° FT. Ir NO F.', r+ �; �,7/ �_�-.. ;ter:.f:;,- ^;c:. ,•�l r'?o.31.115 LEVY & ELDR F <,��..,., • �� EC GE ASSOCIATES INC. 70 ES9I.EST P°1AiiJ STREET CEtiTERVILLE.h1ASSACNUSETTS 02632 �NOG 0UNt7 , : . . . DAT E: / [� GRO UiYD Lt/A TER A T EL Et! _ -- JOB NO. " SHEET z OF 2-