HomeMy WebLinkAbout0074 SHERYLE'S WAY - Health 74 SHERYLES WAY, MARSTON MILLS
A - IG
No................_..... Fics.
THE COMMONWEALTH OF MASSACHUSETTS /�O0 fC q/&
BOAR® OF HEALTH P,4&e- rI
............O F...Ida... 'eF
..............._+ ..rt�
Appliration for Uigpooal loorkii Tomitrurtion Prrmit
Application is her by made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at• '�
..
Location-Address •- r Lot IVo.
...... ... _(dJ.......)o .n�. .a erg. .�_L.,-------------- - C® u,:.t-..... �
W .ZCC•�� / Owre: i Address
...0 ueI......._C.Cc-�Z. .,C ......----•......................... ..._ �71e=------.1.44.....-�e-;1,1'
� Insta:ier Address
Type of Building Size Lotey.. _..Sq. feet
U Dwelling—No. of Bedrooms...............Z...............--.....Expansion Attic (/1,/C) Garbage Grinder JWQ
'04 4 Other—Type of Building No. of persons............................ Showers — Cafeteria
P4 Other fixtures ......--•--•-••-•-----......•• • .
Design Flow.........,/-. AD...................gallons per person per da . Total'daily flo Z...3►.. ..........--gallons.
P4 Septic Tank—Liquid capacity/,06.0.gallons Length.S.'.4..... Width.q.-::/O. Diameter.................Depth...�..•-Y.
Disposal Trench—No.-..-----.--_------ Width.................... Total Length..................... Total leaching area------..--_..-.-__-_sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date............................ ---
minutes per inch Depth of Test Pit. 1o. Depth to ground water---
,� Test Pit No. 1----�.� P P / --�------- P �' -«� -----_--'
f% Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.-..---------------.---.
--------------•---------------------. .............. ............... ......----•----------................I..................o T......._.
O Description of Soil-_--- ,C?. ..... .. (✓ `_So? ' J `'--------------- .e............ .r -�
V -------------------
---------------------------- ---------------------------------------------------------•-----------------------------------------------•------------------------------------------------...............
0 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 ii i L 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Application Approved B -.-�. e
PP PP Y -------------- ----_---
Dat
Application Disapproved for the following reasons:..............................................................................................................
---------------
••-----------------------------------
----------------------------
--------------------------------------------------
-------------------------------------------....
Date
-� ?Permit No... ...:.......... ........�....C ...... Issued .......
Date
. -- �--
a THE COMMONWEALTH OF MASSACHUSETTS f� n,
BOARD OF HEALTHA��
, VVftratiun for Ui4puual Works Tum1rnrtion ran it
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual. Sewage `Disposal
System at
Location Address or Lot No.
u 1- .... ..: -..nJ nl.e er - t.E--------------- a. __Ccsf , f_.... r..�?r..• r_�.-----'E'!Q.............
i''�,
Owrer ..f ddress
�L.-------�r _ 1�------------•-••---•--•-------------- �a5 F......-.....4 ...........�..�tt�7�i�1
Installer Address rr
d Type of Building Size Lots2_4i__ � ____Sq. feet
U Dwelling—No. of Bedrooms ...................Expansion Attic (lQ Garbage Grinder G)
aOther--Type of.-Building ............................. No. of persons ._._._.__ ..... ::.... Showers ( ) = Cafeteria ( )
Q' Other fixtures
ell
W Design Flow......../ 6.-... ._.._ gallons per person er day Total d >ly flo .. gallons�r
i, i
1x Septic Tank 'Liquid capac> (� .gallons Length . L.._-_- W>dth _._/Q. Diameter..._. Depth ' ..
Disposal Trench—:\?o. .......... ..:.... Width._ Total Length___................_ Total.,leaching area=°'` sq ftt
Seepage Pit No--_----------------- Diameter---------------- Depth below inlet.................... Total leaching area_.................sq. ft
Z Other Distribution box ( ) Dosing tank ( )
a T 'mmu by------•---...--•---•-•-•------...... ------••-•�,• Date -•--
Percolation Test Results -,.,Performed
Test Pit No. 1....4s _ mutes pet inch. Depth of Test Pit//k.f........ Depth to ground water..]'V l""T: ...
(Tq Test Pit No. 2................minutes ptrAIiich Depth.of Test Pit................. Depth to ground water
Are I
Description of Soil... 4........... �Q e. !�" % ( 1.�+, +� s
G Gf y f
U -----••---••......•---• -/ .........8_dV.! .....14t?.W...�.... ......S! A.d.....................................
W ------------------------------------------------ - -------------------•-•----••--._....--••---=•--•-•-••---••--••-------••--------•----•------•-----•-------•----•--•--------••-•--•-•--•-•-------•.
UNature of Repairs or Alterations—Answer when applicable.................tA ---i.___ . _
Agreement:
The undersigned agrees;to'install the at6r, described, Individual Sewage Disposal System in accordance with
...,,
the provisions of 1iIT.. . 5) of the State,Sanitary -Code_, The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued-by the-board of health.
gned 9..
_N
Application Approved By e.... �S
-----•- .................................. ................
Date
Application Disapproved for the following reasons:-----•--------•-----••-•---•------------------------•-••--••---------------------------------------------•---•-
----------------------------••--....------•-•------------•--...----------------------..........------......----------------------------------.---•-••--•---•----••--•---•---•--•--•••-•.•-------....--•--
Date
PermitNo......... - ��? -------- Issued-.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
l..... .....f`J OF....... ........: ..........................•...................•..•..
Tntif irab of Tomplittnrr
THIS IS Tg_C.E.RT FY, That the Individjal Sewage Disposal System constructed ( ) or Repaired ( }
-�- L 4•--•-•-•-•-••--••-. !by--------------------------- ------ _:.:. ----------
Insf�,ller
has been installed in accordance with the provisions of TITI : j 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 GUAR NT E THAT YHE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.................. t.-?.........---•-••---•-••-_. Inspector....r)t-e ----- •----•-•---------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...........................................OF......................................
.�........---•---••---•................ �-
......................... FEE.__...-•--••-•--•.......
Uiu, nl Worko Tonstrurtion anttt
Permission is hereby grante .. -- .......... -•----•----------•---•------•-----------------------•------.-•---.-----_._..
to Construct ( or Repair ( an Indiv;dual Sewage D's al y
Str eet
as shown on the application for Disposal Works Construction Permit_NQ �?U Deed..`._�!..(��/...... .
r
�V �,��•'
Board of Health ---...-
�1 7 yrf 7
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
TOWNS t �ARNSTABLE
yam, r y Ay
LOCATION- LPII�S 1/ i�I IS �?. SEWAGE #
VILLAGE�g� ASSESSOR'S MAP & LOTA � " 05�
INSTALLER'S NAME & PHONE NO.� ( lO.l�
SEPTIC TANK CAPACITY <6.0���.
LEACHING FACILITY:(type)�1 (size) O6
NO. OF BEDROOMS. PRIVAT WELL,OR UBLIC WATER_
BUILDER OR OWNER12
]DATE PERMIT ISSUED: - 7 �v
DATE .OOUPLIANCE ISSUED-
VARIANCE GRANTED: Yes_�N®
`I Q Q
7 �
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAI
DEPARTMENT OF ENVIRONMENTAL PROTEC
ONE WINTER STREET, BOSTON MA 02108 (617)292-5500
tfj � �1. ftU• OXE
C ioner STY
``f'
ARGEO PAUL CELLUCCI � 'TD B UHS
ty� "
Governor �F iYY
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A ti~
CERTIFICATION
// / ' t 1
Property Address: 7y S/IP CS / Name of Owner) m r^,b, j3e,- Q
A44 eS,6o,wS/ oq,71$ ^4A Address of Owner: ,.
Date of Inspection: I J ,¢ L>r•I l9 99rv/14
Na
me of Inspector:(Please Print) J Na S kt'J[
I am a DEP��owad em inspector pursuant to 'on 15.340 of Title 5(310 CMR 15.000)
Company Name: &I-A S /ti,e
Mating Address: Y,a ,3 Cx 7a•-9 PGwrs Ze e r p"i4 0 z-3 s,
Telephone Number:
CERTIFICATION STATEMENT
1 certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
Passes
Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
Fails
rr
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 thirty(30)days of
completing this inspection. If the system is a shared system or has a design flow.of 10,000 gpd or greater,the inspector and the system owner
shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to Vm
system owner.and copies sent to the buyer,if applicable,and the approving authority. .
NOTES AND COMMENTS
revised 9/2/98 Pagel of11
�s
Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 7n 5_41 rla XlCs wlq� "4q'.kS4_A's Out 11 s
Owner:
Date of Inspection:
INSPECTION SUMMARY: Check A, B, C, or A
A. SYSTEM PASSES:
1 have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any fai::re
criteria not evaluated are indicated below.
COMMENTS: S�eS I0OWS 4-' e
B. SYSTEM C DITIONALLY PASSES:
One or mores em components as described in the "Conditional Pass"section need to be replaced or repaired. The system,upon
completion of the lacement or repair,as approved by the Board of Health,will pass.
Indicate yes,no,or not determine (Y,N,or NO). Describe basis of determination in all instances. If"not determined",explain why not.
The septic tank i etal,unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance(attache ndicating that the tank was installed within twenty(20)years prior to the date of the inspection;or
the septic tank,whether not metal,is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The sy m will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Hea
�A
Sewage backup or breakout or high stati water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken,settled or uneven distrib ion box. The system will pass inspection if(with approval of the Board of
Health).
broken pipe(s)are replaced
obstruction is removed
distribution box is levelled or replac
_ - The system required pumpirtgmore than four times a Yeard to broken or obstructed pipe(s). The system w8tpess=
inspection if(with approval of the Board of Health►:
broken pipe(s)are replaced
obstruction is removed
revised 9/2/98 Page 2of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 7 q s ��,l0.5
owner:
IM.�es, s wt,7ls
own :
Date of Inspection:
C. FURTHER EVALUATION IS EQUIRED BY THE BOARD OF HEALTH:
Conditions exist which r quire further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health,safety and a environment.
1) SYSTEM WILL PASS UNLES BOARD OF HEALTH DETERMINES N ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM
IS NOT FUNCTIONING IN A NER WHICH WILL PROTECT THE PUBLIC HEALTH.AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is with 50 feet of surface water
Cesspool or privy is withi 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEAL (AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS
FUNCTIONING IN A MANNER THAT PROTECTS THE UBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: -
The system has a septic tank and soil absorptio 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 soil absorption stem and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption sy tern and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption sys m and the SAS is less than 100 feet but 50 feet or more from a
private water supply well,unless a well water analysis or coliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility and the pre nce of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm. Method used to determine distance (approximation not valid).-
3) OTHER
revised 9/2/98 Page 3of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 7 5! J4� ~s aAmz M4412 S�s
Date of •'Inspection 11
r��� ��C
D. SYSTEM FAILS:
You must indicate either Yes" or"No" to each of the following:
I have determine hat one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this
determination is ide tified below. The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
Backup of sew a into facilityor system componenhdue to an overloaded orelogged-S-AS-or-cesspool. :�•Y,
Discharge or pond g 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 'stribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is I s than 6" below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 'mes in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped_.
Any portion of the Soil Absorption stem,cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is wit in 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within one I of a public well.
Any portion of a cesspool or privy is within 50 f t of a private water supply well.
Any portion of a cesspool or privy is less-than 100 et but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has be analyzed to be acceptable,attach copy of well water analysis for
»coliform bacteria,volatile organic-compounds,ammoni nitrogen and nitrate nitrogen. -
E. LARGE SYSTEM FAILS:
You must indicate either "Yes" or"No" to each of the following:
The following criteria apply to large systems in addition to the criteria ab ve:
The system serves a facility with a design flow of 10,000 gpd or greater(L a System)and the system is a significant threat to public
health and safety and the environment because one or more of the following nditions exist:
Yes No
the system is within 400 feet.of a surface drinking water supply
the system is-within 200 feet efa-tributary toe surface-drinking-water supply ----• - --- •• --
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Ar :IWPA)or a mapped Zone II of a public
water supply well)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.3 (2). please consult the local regional
office of the Department for further information.
revised 9/2/98 Page 4of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
'/ / CHECKLIST
Property Address: 77 e e�`rS Lt,)Cy J(-Q�.S� S t^A /S
Owner: 1 � C
Date of Inspection:
Check if the following have been done: You must indicate either"Yes" or"No" as to each of the following:
Yes X No
Pumping information was provided by the owner,occupant,or Board of Health.
_ None of the system components hava been punq*d4oratJeast two weeks and-the system hasbea --mceiving ewmal.flow
rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection.
_ As built plans have been obtained and examined. Note if they are not available with N/A.
The facility or dwelling was inspected for signs of sewage back-up.
_ The system does not receive non-sanitary or industrial waste flow.
_ The site was inspected for signs of breakout.
All system components,excluding the Soil_ Y P 9 Absorption System,have been located on the site.
_ The septic tank manholes were uncovered,opened; and the interior of the septic tank was inspected for condition of baffles
or tees,material of construction,dimensions,depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System orrthe site has been determined based on:
Existing information. For example, Plan at B.O.H.
_ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)
[15.302(3)(b)1
The facility owner(and occupants.if different from_owner).:were.provided.with informatiomon.the.prnpar.rnainEennvwA f
SubSurface Disposal Systems.
revised 9/2/98 Page 5of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address• -7`� S�Ge'y r s w - Ua 4,q-S 41 s
Owner: I',,, 1:".�jy
Date of Inspection: ^1 �TK t 1_�..{
�
FLOW CONDITIONS
RESIDENTIAL- A
lDesign flow:�g.p.d./bedroo . �0�a P� beAeda, f ,
Number of bedrooms(design): Number of bedrooms(ectual):I-
Total DESIGN flow
Number of current residents:
Garbage grinder(yes or no):--"6j Q
Laundry(separate system) (yes or no):,-V—LI) If yes,separate inspection.required _
Laundry system inspected (yes or no)
Seasonal use(yes or no):J—j0
Water meter readings,if available(last two year's usage(gpd):
Sump Pump(Yes or no): /,!J,A ! �'7 d O 043 4/ �� �Cf�Q- -ej
Lest date of occupancy:—mow—/t/ U
COMMERCIALANDUS
Type of establishment:
Design flow: opd sed on 15.203)
Basis of design flow
Grease trap present:(yes or no)_
Industrial Waste Holding Tank present:(yes o o)
Non-sanitary waste discharged to the Title 5 sys :(Yes or no)_ (A
Water meter readings,if available:
Last date of occupancy:
OTHER:(Describe)
Last date of occupancy:
GENERAL NFORMATION
PUMPING RECORDS and source of'nformatiory �
System pumped as part of in action:(yes o no)
If yes,volume pumped: /� gallons
Reason for pumping:
TYPE OF SYSTEM
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) (if yes,attach previous inspection records,if any)
1/A Technology etc.Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components,date installed{if known)-and source of•iwformation: s y�• x- r xJS 1 <`�[/
Sewage odors detected when arriving at the site:(Yes or no) ( ly
revised 9/2/98 Page 6of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: ' 7'( 5 rs 6'Aa�' — p4C-910,s w yl_s
Owner: Jnt
Date of Inspection:
BUILDING SEWER:
(Locate on site plan)
Depth below grade:_^ e�
Material of construction:_cast iron 40 PVC_other(explain)
Distance from private water supply well or suction line
Diameter y „
Comments:(condition of joints,venting,evidena of leakage,-etc.) _
SEPTIC TANK:
(locate on site plan)
Depth below grade:
Material of construction: concrete_metal_Fiberglass _Polyethylene_other(explain)
If tank is metal,list age Is-age.confirmed by Certificate of Compliance (Yes/No)
Dimensions: ti 61 -x r
Sludge depth: Cle fa,o-O r
Distance from top of sludge tobottom of outlet tee or baffle:��'
-"1 -
Scum thickness: Yaw J
Distance from top of scum to top of outlet tee or baffle: /_ /
Distance from bottom of scum to bottom of outlet tee or baffle: �r✓c/ '00 v� 7l C
How dimensions were determined:
Comments:
(recommendation for pumping,conditio of inlet and outlet tees or-baffles,depth of liquid level in r ation to outlet invert,structural-integrity,
evidence of leakage,etc.) e Y
L is1'
GREASE TRAP:
(locate on site plan)
Depth below grade:_
Material of construction:_ ncrete_metal_Fiberglass _Polyethylene_other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of ou tee or baffle: `
Distance from bottom of scum to bottom o utlet tee or baffle: J�,`./I
Date of last pumping:
Comments:
(recommendation for pumping,condition of inlet and tlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage,etc.)
revised 9/2/98 Page 7of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
'/ J / SYSTEM INFORMATION(continued)
Property Address: -7`/ S�Y/L�/(�S _ 1-+ t54v,3 ``1,71S
Owner: J,�,, a- .Q_ C y 3c..._cta F 4-
Date of Inspection: l
TIGHT OR HOLDING TAN - (Tank must be pumped prior to, or at time of, inspection)
(locate on site plan)
Depth below grade:_
Material of construction:_concrete etal_Fiberglass_Polyethylene_other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm present
Alarm level: Alarm in working order:Yes \etc.)
Date of previous pumping:
Comments:
(condition of inlet tee,condition of alarm and float sw
DISTRIBUTION BOX:_
(locate on site plan) Q
Depth of liquid level above outlet invert: N d t �d� o Lox- Q
Comments:
(note•if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) -
S
PUMP CHAMB
(locate on site plan)
Pumps in working order:(Yes(Ye or No) � t
Alarms in working order o o) )X
Comments:
(note condition of pump chamber,co ition of pumps and appurtenances,etc.)
revised 9/2/98 Page 8of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
// SYSTEM INFORMATION(continued)
Property address: 7`( Set rs W
Owner: J a.,Q C.
Date of Inspection: �, A p it.1�9
SOIL ABSORPTION SYSTEM(SAS)� a
(locate on site plan,if possible;excavation not required,location may be approximated by non intrusive methods)
If not located,explain _
X I `Je-JQ ! c J 40
Type.
leaching pits, number:a I BpP,.1 �,1
leaching chambers,number:_ /
leaching galleries,number:_
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:_
Alternative system:
Name of Technology:
Comments:
(note condition of soil,signs of hydr lic failure,level of,ponding, damp soil,pl°ndition of vegetation, etc.) /
n S e h� 24J�,`L A,lv-ao.r ,moo+,1i.=" _f?, , ®Q� �C,4PTC� +�Y1
/ ''
CESSPOOLS:_
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet inve .
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow(cesspool must be pumped as pa f inspection)
Comments:
(note condition of soil, signs of hydraulic failure,level of pondin 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 vegetati ;etc.)
revised 9/2/98 Page 9of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: -7 S� rs (tJ4,/
Owner: cJ 1"k a eL' Cik1 13c�
Date of Inspection: ( / 1
eA
SKETCH OF SEWAGE DISPOSAL SYSTEM: �,� f ��C
include ties to at least two permanent reference landmarks or benchmarks p P )Y
locate all wells within 100'(Locate where public water supply comes into house) I
371 1
0
ao'
was ;�s��•
`.1
revised 9/2/98 Page 10of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
/ f SYSTEM INFORMATION(continued)
Property Address: 7 4 sh e ely r. s G14._ m 41_S7�" c V`'l.•1 t.S
Owner: J►'. Aj C "�_' Q
Date of Inspection:
NRCS Report name
Soil Type_
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep
SITE EXAM Slope k. YeZQ J✓ S�o�{S
Surface water IJOW IE'
Check Cellar
Shallow wells �j
Estimated Depth to Groundwater13 Feet se,,-
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design PI on record
Observed.Site Abutting property,observation hole,basement sump etc.)
Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
Checked pumping records
Checked local excavators,installers
Used USGS Data C St C .4,
Describe how you established the High Groundwater Elevation. (Must be completed)
U s S 05 S, 0V c
III v-r_
�q S� IDS F4-
revised 9/2/98 Page 11orn
• �c t�
http://massl.er.usgs.-ov/current cond/wellstats.jan.98.txt
Table 2.--Statistics of monthly HIGH, LOW, and MEAN ground-water levels, in feet bel
[Statistics are based on monthly readings from start year of record through Septembe
ACTON 158
JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV
HIGH 16.73 16.35 15. 94 14 . 98 15.70 15.55 16.56 17.71 18. 68 17.44 17.45
LOW 21.86 21.08 20.46 20.00 20. 10 20.34 20. 62 21.00 21.36 21.50 21.56
MEAN 18. 92 18.71 18.20 17. 69 17.85 18 .19 18.84 19.42 19. 91 19. 95 19.76
ANDOVER 462
JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV
HIGH 12.77 12.90 11.83 11. 90 12. 63 11.72 12. 90 13.51 13. 99 13. 63 13. 68
LOW 18. 66 19.75 18.01 19.26 20.76 21. 60 22.56 21.75 20. 67 20.70 20.30
MEAN 14 . 65 14.72 14 .21 14 . 12 14 . 65 14 . 91 15.36 15.42 15.53 15. 19 14 .94
ATTLEBORO 83
JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV
HIGH 1. 98 2.92 2.22 2.78 2. 69 3. 12 3. 65 3. 60 3.15 3. 16 3.03
LOW 4 .31 4.19 3. 93 5.22 4 . 19 4 .54 5.00 5.23 5.21 5. 14 5.04
MEAN 3.50 3.45 3.24 3.47 3. 62 4 .02 4 .45 4 . 49 4 .30 4 .08 3.77
BARNSTABLE 230
JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV
HIGH 21.35 21.47 21.45 20.74 20.51 21. 66 21.44 21.31 22.45 20.92 21. 16
LOW 26.10 25.91 25. 95 25.74 25.85 25.32 25. 62 26. 14 26.55 26. 59 26.35
MEAN 23.74 23.64 23. 15 22. 90 23.01 23.30 23.76 24 .31 24 .53 24 . 69 24 .57
BARNSTABLE 247
JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV
HIGH 21.75 21.72 21. 69 20.52 20.71 21.06 21.52 21.80 22.32 22. 60 21. 91
LOW 28.31 28.33 . 28. 16 28.21' 28.30 27 .74 27.82 28.12 28. 43 28. 64 27.79
MEAN 24 .78 24 .52 24 .15 ''�23.72 23. 67 23.80 24 . 11 24 .49 24 .83 25. 11 25. 14
0 BECKET 12
JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV
HIGH 2. 63 2.73 2. 61 2.36 2. 80 2. 95 2.56 3.31 2.57 2.75 2.68
LOW 4 .30 4. 17 4. 16 3.86 4 .18 4 . 44 4 .62 4 . 62 4 .49 4 .55 3.82
MEAN 3. 64 3.54 3.40 3.35 3.54 4 .02 3.83 3. 95 3.75 3.53 3.29
BILLERICA 363
JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV
HIGH 2.31 2.31 0.73 1.91 3.04 4 .05 6.22 7.51 8.22 4 .40 3.86
LOW 11.75 10.07 10.89 8. 15 9.21 10.16 11.50 15.00 15.00 15.00 12. 60
MEAN 6.39 5.83 3. 96 4 .27 5.38 7. 18 8.89 9. 97 10. 61 9.89 8.24
BLANDFORD 9
JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV
HIGH 2. 15 2.25 1.79 1. 92 1.89 2.33 2.35 2.27 2.13 1.75 1.85
LOW 2.90 3.00 2. 93 2. 98 2. 95 3.20 3.42 4 . 60 3.54 2.83 2.79
MEAN 2.50 2.53 2.46 2.31 2.50 2.78 2.89 3.04 2. 63 2. 39 2.28
BOURNE 198
JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV
HIGH 30.54 30. 62 31.09 29.88 30.05 30. 92 31.46 31.88 31.46 31.81 31. 44
Low 35.93 35. 97 35.51 35. 60 35.73 35.29 35.51 35.82 36.05 36. 17 35.90
MEAN 33.21 32.90 32.54 32.24 32.38 32.73 33.22 33. 63 33.89 34 .08 34 .06
BOYLSTON 87
JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV
HIGH 0.84 2. 63 3.48 3. 12 5.05 7. 60 6.87 9. 18 5.28 3.71 3.70
LOW 6.57 6.78 5.86 4 .55 7.48 9.03 12.20 12.20 12.20 4 .01 6.76
MEAN 3.71 4 .70 4 . 67 3.84 6.27 8.51 9.53 10. 69 8.74 3.86 5.23
BREWSTER 21
JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV
HIGH 7.26 7.10 7.08 6. 90 6. 93 7.04 7. 12 7.22 7.45 7.59 7. 60
LOW 12.97 12.96 12.96 13. 10 12. 89 12.80 12. 97 13.04 13.23 13.34 12. 94
MEAN 10.34 10.19 9. 95 9.71 9.58 9.57 9.76 9. 94 10. 16 10.37 10.46
BREWSTER 22
JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV
HIGH 28.97 29.02 28.86 28.15 28.13 28.48 28. 64 28. 69 28.77 28. 97 29. 12
LOW 33. 60 33.45 33.26 33.25 33.28 32. 91 33.05 33.33 33.55 33.57 33.59
MEAN 31.23 31.01 30. 67 30.40 30. 16 30.30 30.67 30.93 31.22 31. 49 31.53
CHATHAM 138
1 of 11 9/2/98 9:15 AM
w
W ~
In ..{
LO
f
THE COMMONWEALTH OF MASSACHUSETTS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BE IT KNOWN THAT
James Kelly
Has satisfied the Department's qualifications as required and is hereby
authorized to use the title
CERTIFIED TITLE 5 SYSTEM INSPECTOR
as provided in 310 CMR 15.340 and Section 13 of Chapter 21A of the
General Laws. Issued by The Department of Environmental Protection.
April 2 ,1996 Vr
tor of the i sion of Wa Pollution Control
TOWN OJARNSTABLE.
LOCATION & SEWAGE #
VILLAGE 1!� ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO.KP_44ye���-��'�
SEPTIC TANK CAPACITY Q D
LEACHING FACILITY:(type) jr =4dl (size) oo
NO. OF BEDROOM pHIVATE WELL OR UBLIC WATER
-,r
BUILDER OR OWNER _
DATE PERMIT ISSUED:
DATE .COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes Ni0 v
77
'PROFILE VIEW OF SYSTEM
FLOT PLAN.
FINISH GRADE: see plot plan Manhole to be within 1 , finish
grade
��'FINISHFD GRADE,
ic
OUTLET INVERT lean out
ELEV.
C)
'T, ELEV.
9772 6 5
INLE
-2 mi ri
ton
Ej
411PVC
recas
OUTLET 7
pipe
sa OUTSIDE 'DI h�
s
'DIA
EFFECl
IT ,
i 6 firl. or 60' c:om' pacted base
t7 6
CAPACITY gals. SEPTIC *7ANK L CHING. , 17.�-
EA1
17, 7
NO.
TANK 7E, rA ' OF TANKS
(-T
' cretei-
s e,pti!;, 'a 1h
ft. 'to on
PLAN VIEW OF.. SYSTEM
10
All sonlifori-ises to be*41 at
3 :1
the convorline of tha lank
oo
shL (3/4- 1 z one
Z
min.
4
1pe
lipVc
OUTSI
4"PVC tight IoW pipe 13
SEPTIC
-LE-AC -� ' PIT ;
G
ReInforcod Corill
TA -y2
T
_S G N DATA N OT E'S'.
DE;
Bedr
ns p6i-,,dAy 1. Elevation an,assumed,datum'��' "
6r, b e M
droo
ge disposal. unit i s rk (BM) is shown on:Plot-Plan. Elel�
Bench MA
sts performed in- accordan' 6e, nm tal �C o'det,"( it"le
T f
j , I I -- -t 6 d c
I - A 17" a
jo \ . ' iystem. 2. S w t�e' Mass.-.State' Env ro
A P r 3. All construction to,c' dnfor the 'Massi`,Stat`6 Env rohmentat e - Titiei,5�, and- the 0
Average d a i f I ow Board oftlealth requireme ts
=33.Q xj_U =_y n
.�y gals.
fany must,ite th p,roposed
�7 Size of tank pro 4. 0
eterious�mat removedfr6m beneath
v All topsoi and del '.
'T -of , file t m-t1lidirections t ere
achin ce.� 6 fro f r6m 'And it ORS -.,I e 9 facility- and_,,for 'a distan' h
Percolation rate, requyr,
,IDD - �)3 td
inches'below',the level�of' th ('n I b oil. aibkfill,� as i ' ',w, th 'a
mpi
ay,organic -matter, and - s
a
Sidewall loadi -clean grav�l or sand materi 1, f tee' from f ifies"," I ' I
sf/day,
/00 — - I I I I : �, I I � I I
ctol Ile) gals./sf/day-. perculati&n rate, in_,its original ,location, and after 2-placement, of
D. LEACHING ARE&REQUIREMENTS
nt the,c oes not war"ra haT�a r �o e 'gro' d4e; g,. boulders
engineer d un or le ge:
gn
o otber�,un ergroun str
Sidewall loading provided i-j.Lrsf:x ucture'st'
or the location of pipes r
gals/sf/
-,,must�h -rater 11 ni
day =�Ujgpd. 6. All washed s e leaching' area�� aVie-leis than� 0 2% of tfie I a f ii er, tha6,�
H.0 0 1- F T
-; a number 200 sieve as determined by�th,e AASJIO ,test.,met ods T-11 and Z-2'� edift. n
5
7. Tight joint piping to consist of Polyvinyl Chloride,,pipe ,'(PVC).,_All "j*oinis -beti4cen-'cofiibretb�',",
day =J51gpd.
_5?Pgpd. de watertighto- accordii��h Plot Fla �-,and Schedule� of�'Elevat n�s
hu AL� 8. Finished .grading to be done in n
Cgpd. Leaching
r garbage d itt�e
isposal. a e perm d to pass over, theleachimig acility.
tructure maybe� ostc the 100% ,e)�pansion 'Area.
s ,sys em c, ed-,-1,
hi t
will not be responsib mance 6f,,,4 s. const%,U t
11*%,4,,.Walker Eng le,lfor :the perfor u
_h��design e
t ..be ippibve d in
wn aiion's a writing' by -ti ng neer.:
SOIL DATX
12.' Thelocal' Board of, Heajt� shall,' e uire inspection:of,'all'constructio�n bythe ,
PERCOLATION TES
L%ngineer or by an agent Of the Board of 'Health adi- eire sudb.persbn� o-certify,
LEGEND
d cc o
;riting, tbat all the ,work has been,complete in' a ordance with the terms f- the Hole Date Depth Elevation- Rate
. ........ :and t eppr"ed plans -�year.
13' F e rformance, itht- septic tank,should'be'',ichecked� at leasvonce4
XX�-�...��..PROPOSED CONTOUR ENCI.............EXTIRA HEAVY CASTOM i
t� A,,
ra*XX.X FIN13MEO SMADE W—.......WATER SERVICE LINE IV CA t
3 Al A I N S R r- 6T _YA R At 0 U IA 0,267S
APPLICANT FOR A MSM'
PRO]
xx�_� .......APPROX.PROPERTY LINE B
......EXI"Q CONTOUR Ivo DEEP HOLE DATA TO
&,A
Deep, Te
STINQ �SPOT ELEVATION W, 'Date,
XXXI...........EXI 0 .......OVERHEAD WIRES t Hole 1. Date
st Hole' 2.
h F1 eva t i on
HOLE LOCATION D........STORM RAIN PIPE Dept Flevations Dppth� Soil Lot
Date T A,M_
TO P -,,A V L) TO P A Al
......POLYVINYL CHLORIDE PIPE 12 ............CATCH fAASIN
90UND 3
M /0 r-, r) 1b
/V
7,
OF ELEVATIONS SCHEQULE S A 4/4) \jG I N E ERI N
E T(jP ,Or FOUNDATION INVERT AT DISTRIBUTION Box rNUT 0
INVERT AT DISTRIBUTIO -10 -crd '�,Yate
mball -St.:'
Kin'
BASEM11iT"MOOR X OUTLETS NOrd ;Wate'r
0
Ll
INVERT AT -.FOUNDATION PIPE - '.:INVERT AT LEACHING Pl-t INLET lchertown -2 , 7
-9-6 / 1)0 - r,Al C 0 0 417F- CP _'IT,A eERT, AT'SEPTIC�TANK INLET -INVERT,-AT LEACHING END
'INV 0' 2
3�
413
NVER I UTLM ELEVATION AT BOTTOM "
I T
_ „..
-
20 PT. MIN.
EXISTING FOUND.
SOIL TESTS TOP OF
EL = 7918 10 FT. MIN.
OBSERVATION HOLE I OBSERVATION HOLE 2 OBSERVATION HOLE 3 CONCRETE 4 SCH 40 PVC CLEAN SAND "
' °y � S T
DATE OF TEST '4" ICO DATE OF TEST DATE OF TEST COVERS PIPE- MIN. PITCH
WITNESSED BY M, WITNESSED BY WITNESSED BY 1/8" PER FT CONCRETE
AT MIN. INCH PERC. RATE MIN./INCH PERC- RATE MIN./INCH COVERS - U
PERC RATE ��— / a. 4 CAST IRON (OR
TEST T3 $'f4 ELEV = -to ELEV. = ELEV.= EQUAL) PIPE- MIN. �12"MAX
Q„ PITCH 1/4 PER FT. o Z
TOP v S�3Ct. 2I-0It 2 /o MIN
sa - '
FLOW LINE a, a LEVEL , 't E1AM�ICIS
� EL.=67.0 0 _ i
` 10"
'MILD E, T i L.1r EL= 74.3 _ o: 2 E L = 73.2
UNSUITABLE MIN.
E L=
° �tvE ,
EL= 74.0 EL 73.�. o O
84' EL.= 63.0 EL = 73.2 c
ME.D1v.M SP�i>1d EL= 72.7 o
DIST o d- 0
14 BOX b PT
LOCATION MAP
t1 O WATER AT 14� EL= WATER AT EL = WATER AT EL =
D
moo GAL PRECA
SEPTIC BASINSORLEQUIV. o EL = 66.7 LEGEND
TAN K
EXISTING SPOT ELEVATION OOxp
10' o EXISTING CONTOUR - - --00 - - - - - - -
10'7 FINAL SPOT ELEVATION
r-
FINAL CONTOUR
PROFILE OF - - - SOIL TEST LOCATION
SEWAGE DISPOSAL SYSTEM BOTTOM OF TEST HOLE EL = _
ADJUSTED GROUND WATER TABLE ( / / ) EL = TELEPHONE POLE
�� � •�` %4° NOT TO SCALE
HYDRANT �'
TOWN WATER N/....�� -- .....�.■W......�
CATCH BASIN tm
r 3 - FRAME 8 COVER SHALL BE
SET WITH MASONRY UNITS
7WHICH ARc.- TO BE MORTARED
CLEAN SANIN PLACE D
GIENERAL NOTES-
'""� .�' It- I. ALL WORKMANSHIP AND MATERIALS SHALL
� �- /B LAY
WASHED
STONE CONFORM TO D.E Q E TITLE 5 . AND THE
s . . . .. I l TOWN OF �AR,At .Tt+I L�-__RULER a REGULATIONS
c FOR THE SUBSURFACE DISPOSAL OF SEWAGE
- I
tf jr �' _ ! -� _ Q 2.ALL COVERS TO SANITARY UNITS SHALL K
BROUGHT TO WITHIN 12'1 OF FINISHED GRADE
� � L
3/4"- I 1/2" 3.EXISTING AND FINAL GRADES SHALL REMAIN
WASHED STONE ESSENTIALLY THE SAME
Q Ua j 4. N0 DETERMINATION HAS BEEN MADE !!Y THIS
"� i--- PRECAST LEACHING OFFICE AS TO COMPLIANCE - WITH TOWN
�- _ ZONING REGULATIONS. OWNER / APPLICANT IS
a c ,� BASIN OR EQUIV TO OBTAINSUCH DETERMINATION FROM
v APPROPRIATE AUTHORITY .
f -- 24 DIA COVERS —
T u r / / r/ r r. r I 5. THIS PLAN IS VALID ONLY IF IT IS STAMPED
/ P
t..,c:�►�' "7 / `� �+ �`' . '� ✓' t ,� PLAN VIEW '-..� - 2- .
AND SIGNED IN RED. THIS OFFICE ASSUMES
r
NO RESPONSIBILITY OR INFORMATION CONTAINS
'� �� /� / r , ' / ✓' 3, ' --FRNMES ,OVEF'S SHALL ON COPIES WHICH F DO 1 NOT MHAVE ORIGINAL
O
r BE SET WITH MASONRY UNITS __ _.-- ----------- -- :� STAMPS AND • SIGNATURES
' WHICH ARE. TO BE MORTARED
IN PLACE 6. ALL COMPONENTS OF THE SANITARY SYSTEM
SHALL BE CAPABLE OF WITHSTANDING H-10
o2� - LEACHING PIT DETAIL.. �,' - ---�— — LOADING UNLESS THEY ARE UNDER OR WITHIN
_ INLET o „MIN c- OUTLET NOT TO SCALE IO FT OF DRIVES OR PARKING AREAS. H-20
► r o , LOADING SHALL BE USED UNDER OR WITHIN
¢ -�-0 _ 6 MIN. FLOW LINE ��- - _..i T F /----REMOVEABLE COVER 10 .FT. OF DRIVES OR PARKING AREAS
a _
i
OUTLET TEE -01' FT PIPES
0
' �IO MIN. A`; H..UUiRED
Jl `„Q �1t' � ' � \ , , I LIQUID DEPTH TEE . DEPTH
`... � 5....Y... -_ __� P• � BELOW FLOW LINE —_-�- -- 1
V ,. V / �^ tE MIN. FRONT SETBACK
`$I ;q tom'• �y i� f t -- - ----� __----- _ - c G�. 4 FT 14 INCHES INLET :o•
S S` RP.t�I VS '"" tO�!' / / *`r f 4 FT MIN 5 FT 19 INCHES _—_ OUTLET MIN. REAR SETBACK
6 FT 24 INCHES "� _�; ' LINE MIN. SIDE SETBACK ,l `a
LPL C„ e�D c ✓ r j LIQUID 7 FT. 29INCHES
DEPTH 8 FT 34 1NCHES c (' ?,-- --f6 APPROVED - BOARD OF HEALTH
B M - NNI1. .�P � �. �, DATE AGENT
Po w FZ P'� F `* 'f /4�,� / tff �� � g '.y Qo C� ,� 1 4 '. �.. �,::
INLET TEE PROVIDED
SECTION 5.10.2 PROJECT '
PER SECT � ' i
-.._� � � � ,/� ; '/ ; : .•a• TITLE 5 �L�O,LOCATION:
s���►P EGT ~� <'
y.- Lr
NO OF )UTLETS —, _ �4R�.S" ` � },; '�r+►
_ IFo CROSS SECTION VIEW
�
�O.
APPLICANT. ��►� � L. �
EXIS 32 G ' '
If D I ST BflX DETAIL
SHED , f f Y� r SEPTIC DETAIL AIL _ _ xQg,-T H LAKE �t1`f .i ,P'F .tS. ' ►
r Ioc ,�- r_ ► ,. > �. � r} �si,_..1 T, TANK D --,ZT TO SCALE
!.. r.. SCAI_C T
H* J, 0 JRAI, hVCq
_
I �. A^�� �' R- � �� M�I�T�•R.^ � - �►�POLL,. F� Reg. Land Surveyors Reg, Sanitorians
' DESIGN CALCULAI IONS � •` � - -� � �� got . 35 ROUTE /34 UNIT 2 - P. O. BOX 237
;� . } , �T�`, SOUTH DENNIS, MA.
NUMBER OF BEDROOMS
"'�" GARBAGE DISPOSAL UNIT
n TOTAL ES' 'MATED FLOW
�. GAL/BR./DAY x BR ) .� _GAL./DAY
� / REQUIRED SEPTIC TANK CAPACITY _- _T__.GAL
��` — SAL
ACTUAL SIZE OF SEPTIC TANK ! '' GAL
!LEACHING AREA REQUIREMENTS
_ -�}✓- {�.3�'j err �;;� .,�- ,,,..
SiDEWALL. AREA �•� GAL,i S 1=
BOTTOM AREA .2 GAL./SF _
3 I. K
LEACHING CAPACITY ( BOTTOM SIDEWALLl `a � GAL.
.u±!�� REVISIONS
/// Rs►��" 0 F
�! O ; 1, SCALE DATE:
I'F _ X .Sx { { � .I� l0x x2.5 ;F�Pt1 ��7., �����`�`\' Q`- Or ��
r :
4 x 4i 'r
"= St GAL.
-f RESERVE LEACHING CAPACITY .�
a' s / RiChtARO \% R. 8Y
/F RICHARD <_ J. b � PPD. By:
1 1AMES Tj O'H ARN —
S a E RN go/27871 0� d ISr V'`� `'�� 'f5.. T� •5
�F� t1 �, �StER`� a` JOB NO.:
\a1sT� SHEET - OF . •..
. AWi'1AF
FORM `! 6/ 1115,