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Home My WebLink About0242 WINDING COVE ROAD - Health 242 Winding Cove Road Marstons Mills -- - - -- - — A=057 - 041 Commonwealth of Massachusetts Title 5 Official Inspection Form p � Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 242 Winding Cove Road Property Address Camille Ellsworth Owner Owner's Name information is wired for required Marstons Mills MA 02648 June 19 2009 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: A. General Information When filling out forms on the l�tlp computer use 1. Inspector: tl only the tab key to move your Patrick T. Sullivan cursor-do not Name of Inspector use the return key. Ready Rooter, Inc. Company Name i PO Box 371 -17 Jan Sebastian Dr. Company Address Sandwich MA 02563 City/Town State Zip Code 508-888-2805 S112843 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 June 23, 2009 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. L--11/0 !� 242windingooverd•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Peg of 1 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 242 Winding Cove Road Property Address Camille Ellsworth Owner Owner's Name information is required for Marstons Mills MA 02648 June 19, 2009 every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 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 t replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ or the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years o * or the septic tank (whether metal or not) is structurally unsound, exhibits substantial i Itration or exfiltration or tank failure is imminent. System will pass inspection if the existin tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass ins p ction if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the ank is less than 20 years old is available. ND Explain: ❑ Observation of se age backup or break out or high static water level in the distribution box due to broken or obst cted pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection f(with approval of Board of Health): ❑ brok n pipe(s) are replaced ❑ o struction is removed 242windingcoverd'-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 2 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '< 242 Winding Cove Road Property Address Camille Ellsworth Owner Owner's Name information is Marstons Mills MA 02648 June 19 2009 required for , every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more thary4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with app oval of the Board of Health): ❑ broken pipe(s) are replace ❑ obstruction is remove ND Explain: 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 nvironment. 1. System will pass unless Board of Health deter ' es in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of surface water ❑ Cesspool or privy is within 50 fe of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Bo d of Health (and Public Water Supplier, if any) determines that the system is f nctioning in a manner that protects the public health, safety and environment: ❑ The system has a s ptic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surf a water supply or tributary to a surface water supply. ❑ The system ha a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The syste has a septic tank and SAS and the SAS is within 50 feet of a private water supply w I. 242windingcoverd•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 3 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 242 Winding Cove Road Property Address Camille Ellsworth Owner Owner's Name information is required for Marstons Mills MA 02648 June 19, 2009 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SA s 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 ana sis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presen of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other ilure 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 '/z 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. 242windingcoverd-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 4 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 242 Winding Cove Road Property Address Camille Ellsworth Owner Owner's Name information is Marstons Mills MA 02648 June 19 2009 required fog , every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no" each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 fe of a surface drinking water supply ❑ ❑ the system is within 20 eet of a tributary to a surface drinking water supply ❑ ❑ the system is locate In a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or apped Zone II of a public water supply well If you have answered "yes"to any q stion in Section E the system is considered a significant threat, or answered "yes" in Section D ab a the large system has failed. The owner or operator of any large system considered a significant reat under Section E or failed under Section D shall upgrade the system in accordance with 31 CMR 15.304. The system owner should contact the appropriate regional office of the Depa ent. 242windingcoverd•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 5 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 242 Winding Cove Road Property Address Camille Ellsworth Owner Owners Name information is required for Marstons Mills MA 02648 June 19, 2009 every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] 242windingcove rd•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 6 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 242 Winding Cove Road lug - Property Address Camille Ellsworth Owner Owner's Name information is required for Marstons Mills MA 02648 June 19, 2009 every page Cityrrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 2 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 582 Number of current residents: 1 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? (if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No 148 GPD = Water meter readings, if available (last 2 years usage (gpd)): 200 2007 98 GPD 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 t e Title 5 system? ❑ Yes ❑ No Water meter readings, if availa e: Last date of occupancy/us Date Other(describe): 242windingcoverd•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 7 Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 242 Winding Cove Road Property Address Camille Ellsworth Owner Owner's Name information is Marstons Mills MA 02648 June 19 2009 required for , every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Ready Rooter records: Pumped 05/27/09+05/18/05 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system . ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: System installed February 27, 1985. As-built and engineered plans on file w/Board of Health. Were sewage odors detected when arriving at the site? ❑ Yes ® No 242windingcwverd-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 8 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 242 Winding Cove Road Property Address Camille Ellsworth Owner Owner's Name information is required for Marstons Mills MA 02648 June 19, 2009 every page, City(rown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 12"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: 3"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: 8 X 4.5 X 4.5 1000 gallons Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle 35" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? Tape measure and dip tube 242windingcoverd•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 9 l Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,..°' 242 Winding Cove Road Property Address Camille Ellsworth Owner Owner's Name information Marstons Mills MA 02648 June 19, 2009 required far every page. Cityrrown 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.): Inlet and outlet PVC tees in place. Liquid level at outlet invert. No leakage into or out of tank. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ f erglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scu o top of outlet tee or baffle Distance from botto of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspectio (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fibergla ❑ polyethylene ❑ other(explain): 242windingcov3rd•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 10 i Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 242 Winding Cove Road Property Address Camille Ellsworth Owner Owner's Name information is MarstonMills sMMA 02648 Jun required for a 19, 2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity: /g�allons llons Design Flow: per day Alarm present: Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last um in p P 9 Date Comments(condition of alar/andt switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 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.): One inlet, one outlet. Very light solids carryover. No sign of high water staining over outlet invert. Riser brings cover within 6"of grade. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 242windingcoverd•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 11 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 242 Winding Cove Road Property Address Camille Ellsworth Owner Owner's Name require c fo is Marstons Mills MA 02648 June 19 2009 requirec for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1-6 X 6 w/2'of stone ❑ 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.): Leach pit located and inspected with camera. Liquid level 4' below invert. High water staining 3'6" below invert. No sign of past hydraulic failure. 242windingcoverd-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 12 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 242 Winding Cove Road Property Address Camille Ellsworth Owner Owner's Name information is required for Marstons Mills MA 02648 June 19, 2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspec 'on) (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 infl w ❑ Yes ❑ No Comments (note conditio 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, igns of hydraulic failure, level of ponding, condition of vegetation, etc.): 242windingcoverd-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .'` 242 Winding Cove Road Property Address Camille Ellsworth Owner Owner's Name information is required for Marstons Mills MA 02648 June 19, 2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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. I \ � � � I 3 '/ 3 � 3q 5- O '1 ti i 242windingcoverd•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 14 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 242 Winding Cove Road Property Address Camille Ellsworth Owner Owner's Name information is Marstons Mills MA 02648 June 19 required for , 2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells >4 � Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed. Nov. 14, 1984 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: ma.water.usgs.gov terraserver-usa.com You must describe how you established the high ground water elevation: No groundwater encountered in test hole for perc test at 12' (1984). Base of leach pit 8'. Accessed local groundwater contours and topo mapping. Property elv.= 50. I 242windingcoverd-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 TOWN OF BARNSTABLE LOCATION ua CM2�'.rc��wz (:�Icje SEWAGE# VILLAGEMAP \o4,-5 1 , \AkS ASSESSOR'S MAP&PARCEL 4(1 INSTALLERS NAME&PHONE NO. v l SEPTIC TANK CAPACITY `QZ)0 LEACHING FACILITY:(type) (size) ((MCXD f NO.OF BEDROOMS OWNER PERMIT DATE:�� l�� COMPLIANCE DATE: a gS Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility J Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY Aj,Q �3 1 34 q*L a ?� Sewage Permit No. Location: Sq Village: '��( • /sc.�.� Installer's Name & Address: a�,�l 1 Builder's Name & Address: `,, Ily Date Permit Issued 17-_(7- ® Date Compliance Issued a. a'l ' J 5 cr r p,t e ms � R�g ln ' . ; tl 3 No.........------... �. 0 la PC 5 r ^FD THE COMMONWEALTH OF MASSACHUSETTS 0.5�7 -0y I BOAR® OF HEALTH J4 E s0% .--. .....................O F.........................----............----.------......--------.............----....... V . pphra#inn for Bispos ai Works Tonstrarr#iun Famit - Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal P System at: a ocation-Add or Lot No. ... . Qwl ._... -••--- -�.� -----•---- --�1 � .. .....C"TY. ..I - .r Owner (Address / ,....` ........ .. —.£........................................ -VM H�2�_reefs---...... t � ��llr�S-------•-------•------- Installer Addre6s Type of Building Size Lot....... - _Ut:Z_Sq. feet Dwelling—No. of Bedrooms....................2....................Expansion Attic ( ) Garbage Grinder t-./() �'4 Other—Type e of Building No. of persons............................ Showers YP g ------------------------•--• P (,�) — Cafeteria ( ) dOther fixtures --------------- -•-------••--------•--------••.......-------•••-------....._...----•---•--•---•-••--••------------------....--------....._....------ w Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity_10(16gallons Length............... Width---------------- Diameter---------------- Depth................ x 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 ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ f% Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ p .-••--.---.-•••.................•----. �--------•---------.....-------- -•----------•--.....--------------------- --.... O Description of Soil_...: Gi v�.....•.]/ -e.Ss.GCS. .____.____ �s.K__ x c, -•--•------------------------ -------------------------------------------w U 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 TITLi 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has ben issued by the board of health. Signed. vl . .1. . - .F.. �.... 1�/I.... 2 N_ D. Application Approved By..... ..... ... J+... ........... --------- 7l...................... Date Application Disapproved for the following reasons-----------------------------•-••------------•--•-------.......---------...--•--------------•--••-----........--- ..................................................,...........:............................................................................................................................................ Date Permit No...........q.5.—f t-••' ...2................... Issued.......LD...,�XP41•--•-•-•-•-- Date - -- �o ' y . Fw3 _ THE ooMmowvvsALr* OF MAssAoxuscrrs � BOARD��K� �� HEALTH � ��~^"" ~�° ��" ...........--------- - ..............OF..................... ----- - �.�� Applir« tmou� �� Disposal Works Tonstrurtion ramit Application is 6erc6v made for a Permit to Construct or Repair an Individual Sewage Disposal Systemk � M ,(�, (0 Vf- Rj (114 r Lot � � + u°"� �u�,� , ~ � - .r ` A«drvs ' � . feet Type »f ' Size--2�o of Bedrooms Attic ( ) Gr�der�gftS'm�y�» Pk Other--Type of Building ............................ No. of Cafeteria Showers / �A �� -- Cafeteria ( \ ~�~ ~ ' {)t�or 6�tuc�o .-'------_-_..--..-.-_--------_____________.____________________.______. ^ Design Flow.-_-_'-----_--__'-_ per person per day. Totaldaily 8on�------_'--------. . ] Septic Tank--L�o�� Diameter-.----. Depth................ ` T�u� �� 6 I�� Total �� °'"v"=^ -- '---'-----' ---'----- ^c"m�^'---_--'--' uu /o�mo� .--____�g Seepage Pit No.--_----' Diaoe1cc.----.--- Depth below inlet_------_ Total leaching area.-----.--'mq.* Z Other Distribution box / ) Dosing tank '- Percolation Test Results Performed bv.......................................................................... Date........................................ Test Pit No. l................minutes per inch Depth of Teat Pit.................... Depth tn ground water.--.-..---_. ' (X4 Test Pit No. 2...............minutes per inch Depth of Test Pit.................... Depth toground water........................ _- ---'---_-----'-'-----'__`--'--'---'---'---- �� ofSo�_'�~� ^ ��^'�- -- 0 ________________________._________ __--__-'-_--_-__-___'-----___'----___'--'-__---'-__-'__'__-._--'-__.-----'--'_--------_ �14 -_.-_----._-_-'---__'-_.--.-------__._---_.-'-----._-_'----__----._--------_.___. U Nature of Repairs or Alterations--Answer when applicable............................................................................................... -------'------''--'---'--'---------'----------------------'--'----'-----------------'----- The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with ,4,he provisions of TITIZ- 5 of the State Sanitary Code— The undersigned further agrees not to place the system in bPeration until a Certificate of Compliance has bem issued by the board of health. Date . Date Application Disapproved for the following reasons:.............................................................................................................. � .................................................... ...............'............ Date Permit �Cp% i, ~ Date | THE COMMONWEALTH ormAssAoHuSsrrs ' - --- -- | BOARD OF HEALTH | � ��............................ ................................................. ......_......_............._..' T ��' ' ~°~~°°°~°°~ m°. =~=~°°°p°°==°°° THIS IS - (38-CERTIFY, the Individual So~aQo Disposal System constructed or Repaired by............3_'_....- -- -_ =.................................................................................................................................................... Installer has been installe� in accordance h 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 CONST UED ASA GUA11RI A TEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. . DATE........................... -- ^ ^' -------'---7--------- THE COMMONWEALTH mrMAssxo*ussrrs | | BOARD OF HEALTH �� , , ,_� , ...........................................0F..................................................................................... rvu------------ FEE'±z::�P.......... Permissionis hereby -. ................................................................................................... to Construct 1--) or,Repair an Individual SeA,Jge Disposal System at !!^ ' ~j /' Street as ' --- ooshownoothe application for Disposal Wo�aC��u�o ~ / ---_ Board of Health ....`. � ponw /uss A. Svu ow U U Ire A,——i cl: 's ,y s -C Ci , TOP ;Pi6 SqAoEii OVER . GRA Pit ox, zf;00 '0 �FIWSH GRA -OV8 FINISH 'SPADE �5 Z 0 P FINISH, SEP -'tA NK 61 .= .4ro YIA\\Y71x\\ Y//,X\v NNN"WA, 1c77/A\\yj/A\WMA \7w//,W VARIES,-` V /77177777�M 12' Al 418 -.1120 3 it 46 PRECA CONC.de 'OR S T, 4. :OF NA SHED i,PEA S TONE BRICK & MOP TA R 2 OUTLET PIPE,LEVEL. TO �12 y 8EL ON GAM DE FOR 2 .FT, MIN.: F7777 r46.-44] C. I. OP:PVC TEES 4' �BSMT. FLR� 'GALLON - . Di TRIBU TION BOX EL . '46-00 61 To 1-112 INS TA L L ON LEVEL BASE 'lite PRECA PRECAST 1314 ST.-CONCRETE ASHED H- /0 REINFORCED �,CPUSHED CONCRETE TONE H- 0 , PtIN,4 SEPTIC TANK NO TE.* EYeA VA TE TO ELEV. !�5"tt" OR,-.:INSTALL. ON L E VEL �BASE 14y. 40 L OWER TO REMO VE. ALL IMPERVIDUS MA TEPtA L. BEIVEA TH THE LEACHNG AREA REFL ACE EXCA VA TEO MA 76"1 L NI TH r EA N, CLA Y FREE, SA NO EFFEC T1 VE\IDIA ME TEP LEACHING PIT;, GENERAL ' NOTES _" NST I ALL ON LEVEL-. A -'-BASED ON -A 6 s ul'i D, I ., L L'�,EL E VAIONS :SHOWN ARE E SYSTEM MUST �BE CASTIPON �2., ALL 'PIPES IN --7H -PIT �OR SCHEDULE ,`40 PVC.� OBSERVATION THEBOARO OF BE i'NO TIFIE HEA L TH MUST WHEN CONS TR TION _tS COMPL ETE, PRIOR Ue -PERCOLA TION RA TE:_ BA CKFIL L-i ANGES 'IN �THIS PLAN MUST BE., APPROVED , MIN -ANY CH BY THE BOARD OF HEALTH ANO .'CAPE, , NESStb ' B Y. fSL ANDS SURVEYING 'CO. , I,�Lr. -MA TEPIA1.5 ANO INS TA I L A TION SkA L L, 'BE B)C?D HEAL T 'OF H DA TA' TA TE,SA NI T4 P Y DESIGN_:4 , COMPL IIA NCE'�WI rH THE TE.* COD DA E TITLEJ: AND L9CAL DPOO�G, RUL ES A ND REGUL A TIONS NUMBEP OF BE GAPBAGE� SPOSAL' -6 TH ,APROW 'IS f PECOD�,.PLAIVS AO TO BE" USEO,�FOP :SOLAR PURPOSES 4C) GPI FLOOD _H4 ZA RD .ZONE _ -FL OW,. DAIL Y ' ' SEPTIC TA NK, PEG,,,D.' E-R. L 7 WA TER SUPPL:Y, SEP L� NK PPOVIDED TIC TA -GPD (14 40 L EA CHING PEOUIPED 0 PEA SIDEXALL�. A J000 , LLav S. F� ;w $7,:ctwcjqETE iX Z. re S. TAW BOTTOM., AREA c6 7 S. F. LEGEND S,F. X_iiK_�GIS. F., GPO 'GPO -D �LEACHING_ ,��ROV,66 PRECA 7F LEACWA(S PX PPOPOSEDIELEVATION 'EXISTING CON TOUP LO PESIDENCE, INGLE �FAMIL Y OBSE VA TION PIT 0 , -..DISTPIBU'TION BOX , SY PiqOPOSED,�: 'SE)VAGE.�' DISPOSAL ,,�. STEM JAPES: ORTRAND LEA 04ING I T- . .....PA 'FOP PPE 6 A 4ED! L"-INGTOW. SEPTIC- , TANK o ro L CHA Fi L ES , ESEP VE PI T AREA CO VE , 'POA D L 0 T -2` 92- WIN DING- TUI 8APNS_ -CO -:,MA S- S - A E,`," Ti, 0 CHAPLES %-PIPE.�INVERT, ELE 7 -ST CA PE ISL A 1VDS S Y -�IIVC. UPVE YJVG�,, E 71 0- P. 'PLOT 'PLAN NO TEU 80X:! -334"1 ., SCALE'��AS.z "T CIL A