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HomeMy WebLinkAbout0042 COACHMAN LANE - Health 42_Coachman Lane.,-. t: W `Barnstable... P A = 152_ 042 i Page: CERTIFICATE OF ANALYSIS Barnstable County Health Laboratory Report Prepared For: Report Dated: 6/23/2003 Scordato,Alma&Joseph Order Num er: +0fiVd Joseph M.Scordato 6600 Whitegate Rd. J U L 15 2003 Clarksville, MD 21029 TOWN OF BARNSTABLE HEALTH DEPT. Labora.tory ID#: 0320066-01 Description: Water-Drinking Water Sample#: 20066 Sampline Location: 42 Coachman Lane,West Barnstable Collected 6/4/2003 Collected by: Alma Scordat Received 6/4/2003 Routine ITEM RESULT UNITS MCL Method# Tested LAB: IC Lab Nitrates 7.6 mg/L 10 EPA 300.0 6/4/2003 LAB: Metals Copper 0.3 mg/L 1.3 SM 3111B 6/18/2003 Iron <0.1 mg/L 0.3 SM 3111B 6/18/2003 Sodium 25 mg/L 20 SM 3111B 6/18/2003 LAB: Microbiology Total Coliform Absent P/A Absent 309 6/4/2003 LAB: Physical Chemistry Conductance 274 umohs/cm EPA 120.1 6/4/2003 pg 5.9 pH-units EPA 150.1 6/4/2003 Note: Sample has higher than average levels of Nitrates.Monitoring is recommended(2-3 times per year)to establish any upward trends.Sodium level above average.Those on low sodium diet may wish to contact physician. Approved By: (Lab Director) CID r t I t� i Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 f��OF NAR��T CERTIFICATE OF ANALYSIS Page: 1 in, i Barnstable County Health Laboratory 'rs�rt{vSts� i Report Prepared For: Report Dated: 2/13/2003 RF_r. F� Order Number: GO318825 Joseph Scordato 6600 Whitegate Road F E B `l. v 2003 Clarksville, MD 21029 7(1Vv�ur Javo,<ST'ABLE HEALTH DEPT. Laboratory 11)#: 0318825-01 Description: Water-Drinking Water Sample#: 18825 N316 345 346 Sampline Location: 42 Coachman Ln W Barnstable MA Collected 2/3/2003 Collected by: A Scordato 152/042 Received 2/3/2003 Routine+Ammonia ITEM RESULT UNITS MDL MCL Method# Tested LAB: IC Lab Ammonia <0.1 mg/L 0.1 EPA 350.1 2/6/2003 ....... itrates_ ___.._.___. ::_.._ . :.__..8.6..,.. .. mg/L_ _ ._.._.o.t___. . ._.-t o EPA-300.0 2/4/2003 LAB: Metals- op er xmg/L 0.1 1.3 SM 311113 2/6/2003 :�',.:i�:S.'..r....fi�.1v�+`f' e.. t. _ - r'iI'r _-'�;Y" \\�_.J1,�•n'.' GQ;j mg/L 0.1 0.3 SM 3111B 2/6/200 Iron � 3 Sodium ., Y'29� mg/L 1.0 20 S`M 3 1 1 1 B 2/6/2003 LAB: Microbiologyty. ' Total Coliform Absent P/A 0 Absent 309 2/3/2003 LAB: Physical Chemistry Conductance 274, umohs/cm I EPA 120.1 202603 pH 5.8 pH-units 0 EPA 150.1 2/3/2003 EPA 524.2- Volatile Organics by GUMS ITEM RESULT UNITS MDL MCL Method# Tested LAB: GUMS 1,1,1,2-Tetrachloroethane BRL ug/L 0.5 EPA 524.2 2/11/2003 1,1,1-Trichloroethane BRL ug/L 0.5 200 EPA 524.2 2/11/2003 1,1,2,2-Tetrachloroethane BRL ug/L 0.5 EPA 524.2 2/11/2003 1 1,2-Trichloroethane BRL ug/L 0.5 5.0 EPA 524.2 2/11/2003 1 1-Dichl6ioethane BRL ug/L 0.5 EPA 524.2 2/11/2003 lj-mDichloroethene BRL ug/L 0.5 7.0 EPA 524.2 2/11/2003 i r l-Dichloropropene BRIJ ug/L 0.5 EPA 524.2 2/11/2003 1 •-.Yi is y:'„ r... ',. _ .;1Aa :' �. \0"i 1;2,3-Trichlorobenzene BRL ug/L 0.5 EPA 524.2 2/11/2003 l`;2;3`=T`r chloropropane BRL ug/L 0.5 EPA 524.2 2/11/2003 t Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 r,OF Mqp•. Page: 2 CERTIFICATE OF ANALYSIS Barnstable County Health Laboratory Report Prepared For: Report Dated: 2/13/2003 Order Number: G0318825 Joseph Scordato 6600 Whitegate Road Clarksville, MD 21029 Laboratory ID#: 0318825-01 Description: Water-Drinldng Water Sample#: 18825 N316 345 346 Sampling Location: 42 Coachman Ln W Barnstable MA Collected 2/3/2003 Collected by: A Scordato 152/042 Received 2/3/2003 1,2,4-Trichlorobenzene BRL ug/L 0.5 70 EPA 524.2 2/11/2003 1,2,4-Trimethylbenzene BRL ug/L 0.5 EPA 524.2 2/11/2003 1,2-Dibromo-3-chloropropa BRL ug/L 0.5 EPA 524.2 2/11/2003 1,2:-Dibromoethane(EDB) BRL ug/L 0.5 EPA 524.2 2/11/2003 1,2-Dichlorobenzene BRL ug/L 0.5 600 EPA 524.2 2/11/2003 1,2-Dichloroethane BRL ug/L 0.5 5.0 EPA 524.2 2/11/2003 1,2-Dichloropropane BRL ug/L 0.5 EPA 524.2 2/11/2003 1,3.,5-Trimethylbenzene BRL ug/L 0.5 EPA 524.2 2/11/2003 1,3-Dichlorobenzene BRL ug/L 0•5 EPA 524.2 2/11/2003 1,3-Dichloropropane BRL ug/L 0.5 EPA 524.2 2/11/2003 1,4-.Dichlorobenzene BRL ug/L 0.5 5.0 EPA 524.2 2/11/2003 2,2-Dichloropropane BRL ug/L 0.5 EPA 524.2 2/11/2003 2-Chlorotoluene BRL ug/L 0.5 EPA 524.2 2/11/2003 4-Chlorotoluene BRL ug/L 0.5 EPA 524.2 2/11/2003 Benzene BRL ug/L 0.5 5.0 EPA 524.2 2/11/2003 Bromobenzene BRL ug/L 0.5 EPA 524.2 2/11/2003 Bromochloromethane BRL ugn 0.5 EPA 524.2 2/11/2003 Bromodichloromethane BRL ug/L 0.5 EPA 524.2 2/11/2003 Bromoform BRL ug/L 0.5 EPA 524.2 2/11/2003 Bromomethane BRL ug/L 0.5 EPA 524.2 2/11/2003 Carbon tetrachloride BRL ug/L 0.5 5.0 EPA 524.2 2/11/2003 Chlorobenzene BRL ug/L 0.5 100 EPA 524.2 2/11/2003 Chloroethane BRL ug/L 0.5 EPA 524.2 2/11/2003 Chloroform BRL ug/L 0.5 EPA 524.2 2/11/2003 Chloromethane BRL ug/L 0.5 EPA 524.2 2/11/2003 cis-1,2-Dichloroethene BRL ug/L 0.5 70 EPA 524.2 2/11/2003 cis-1.3-Dichloropropene BRL ug/L 0.5 EPA 524.2 2/11/2003 Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 f Page: 4 CERTIFICATE OF ANALYSIS Barnstable County Health Laboratory Report Prepared For: Report Dated: 2/13/2003 Order Number: G0318825 Joseph Scordato 6600 Whitegate Road Clarksville, MD 21029 Laboratory ID#: 0318825-01 Description: Water-Drinking Water Sample#: 18825 N316 345 346 Sampline Location: 42 Coachman Ln W Barnstable MA Collected 2/3/2003 Collected by: A Scordato 152/042 Received 2/3/2003 Note: Sodium levels are above average. Those on low sodium diet may wish to contact physician.Sample has higher than average levels of Nitrates.Monitoring is recommended(2-3 times per year)to establish any upward trends. Approved By: (Lab Director) 2-I131zC 13 Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 C0MM0NW1i,A1,l'11 OI 1Vlnssnc;alusl;'1"I'S ExiI,,CI_I'I'IVI,,, OI,'1 I(Al�, OI ENV1liONMl�,N'I'Ai,Al-],'AWS r A" b D1 hA1ZTMENT OF ENVIRONMENTAL PROTEXTI.(:N c RECEIVED r FEB 1 12003 TOWN OF BARNSTABLE i_ _ _ HEALTH DEPT. Map: Lot: Par: TITLE 5 OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:_42 Coachman Lane 15 W.Barnstable_ MAP Owner's Name:_David Foster— Owner's Owner's Address: � `-ems �,-,,.Rd. ' _Ch`atham_ 2 LOT Date of Inspection:_2//03/03 Name of Inspector: Dion C. Dugan Company Name:_ 1543 Main St. Mailing Address: Brewster,MA 02631 Telephone Number:_508-896-9390 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: _X_ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: �--�` Date: 2/03/03 g — — 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. _Notes and Comments: *Recommend: Maintenance pumpinga3 5 yrs. . _ *****Recommend tank be pumped now. (14"of sludge in bottom of tank) and recommend tank be maintenance pumped every 3 years. ****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. Page 2ofII OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (con(inued) Property Address: 42 Coachman Lane W. Barnstable_ Owner's Name:_David Foster_ Date of Inspection:_2/)3/03_ Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _X_ 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. Anv failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: N/A One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, setdcd or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND cxP lain: Page 3 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 42 Coachman Lane. W. Barnstable_ Owner's Name:_David Foster_ Date of Inspection:_2/03/03_ C. Further Evaluation is Required by the Board of Health: N/A Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier,if any)determines that the System is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well,water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. J. Other: F f Page 4 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMEN'FS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 42 Coachman Lane W.Barnstable_ Owner's Name:_David Foster_ Date of Inspection:_2/03/03_ D. System Failure Criteria applicable to all systems: You must indicate"yes' or"no" to each of the following for all inspections: Yes No _X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _X_ than Liquid depth in cesspool is less an 6"below invert or available volume is less than 1/2 day flow _X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped X_ Any portion of the SAS, cesspool or privy is below high ground water elevation. _X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] _NO_(Yes/No)The system fails. 1 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: N/A To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes'or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _N/A_ the system is within 400 feet of a surface drinking water supply _N/A_ the system is within 200 feet of a tributary to a surface drinking water supply N/A_ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area— I WPA)or a mapped Zone 11 of a public water supply well If you have answered "yes' to any question in Section E(lie 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. Page 5 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 42 Coachman Lane W. Barnstable_ Owner's Name:_David Foster_ :Date of Inspection:_2A)3103_ Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No _X_ _ Pumping information was provided by the owner,occupant,or Board of Health _X_ Were any of the system components pumped out in die previous two weeks _X Has the system received normal flows in the previous two week period' _X Have large volumes of water been introduced to the system recently or as part of this inspection " _X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) _X_ _ Was the facility or dwelling inspected for signs of sewage back up _X_ _ Was the site inspected for signs of break out" _X_ _ Were all system components,excluding the SAS, located on site" _X_ _ 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 _X _ 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: Yes no _X_ _ Existing information. For example, a plan at the Board of Health. X_ _ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unaccep(able) 1310 CMR 15.302(3)(b)] Page 6 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PA RT C SYSTEM INFORMATION Property Address: 42 Coachman Lane W. Barnstable_ Owner's Name:_David Foster_ Date of Inspection:_2/03103_ FLOW CONDITIONS RESIDENTIAL 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_ Number of current residents: 0 Does residence have a garbage grinder(_yes or no):_no_ Is laundry on a separate sewage system(yes or no): no (if yes separate inspection required] Laundry system inspected(yes or no): _no Szasonal use: (yes or no):_no Water meter readings,if available(last 2 years usage(gpd)): Well>180' away Sump pump(yes or no):_no_ Last date of occupancy:_I2/02_ COMMERCIAL/INDUSTRIAL: N/A Type of establishment: N/A Design flow(based on 310 CMR 15.203): gpd Basis of design flow(sea ts/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no).- - Non-sanitary waste discharged to the Title 5 system (yes or no): _ Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information:_none by owner Was system pumped as part of the inspection(yes or no): NO_ If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM X_Septic tank,distribution box, soil absorption system _Single cesspool Overflow cesspool Privy NO_Shared system(yes or no)(if yes,attach previous inspection records, if any) _ Innovative/Alternative technology. Attacti.a_-copy of the current operation and maintenance contract (to be ; obtained from system owner) _Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all components,dale installed (if known)and source of information: _Installed_4/7/86 (17 years old)_B.O.H.Were sewage odors defected wlicn arriving al the site(yes or no): NO_ • Page 7 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 42 Coachman Lane W. Barnstable_ Owner's Name:_David Foster_ Date of Inspection:_2/03/03_ BUILDING SEWER(locate on site plan) Depth below grade:_4'10"_ Materials of construction: _cast iron X_40 PVC_other(explain).- Distance from private water supply well or suction line:_N/A Comments(on condition of joints,venting,evidence of leakage, etc.): _Joints are tight,venting is through the roof,no signs of leakage. SEPTIC TANK:—YES—locate on site plan) Depth below grade:_X 10" COVER BUILT UP W/IN 10" Material of construction:_X_concrete_metal_fiberglass_polyethylene _otlier(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no)-._(attach a copy of certificate) Dimensions: 1000 Gallon_ Sludge depth _14"_ Distance from top of sludge to bottom of outlet tee or baffle: 16" Scum thickness: _2" 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: 12" How were dimensions determined:by tape and rod Comments(on pumping recommendations,inlet and outlet tee or baffle condition; structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): Recommend tank he pumped now. (14"of sludge in bottom of tank)and recommend tank be maintenance pumped every 3 years. Tank and tees in good condition. No signs of leakage. "Recommend: Maintenance pumping every 3—5 yrs. GREASE TRAP:_N/A—locate on site plan) Depth below grade: _ Material of construction:_concrete_metal_fiberglass polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet (cc or baffle: Date of last pumping: —-- Comments(on pumping recommendations, inlet and outlet tee or baffle condilion. structural integrity, liquid levels as related to outlet invert,evidence of leakage. etc.): Page 8 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 42 Coachman Lane W.Barnstable_ Owner's Name:_David Foster_ Date of Inspection:_2/03/03_ TIGHT or HOLDING TANK:_N/A_(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches, etc.): DISTRIBUTION BOX:_YES_(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.): D-Box with schedule 40i inlet tee is level with some signs of carry over and no signs of leakage PUMP CHAMBER:_N/A (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): . Page 9 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 42 Coachman Lane W. Barnstable_ Owner's Name:_David Foster_ Date of Inspection:_2/U3103_ SOIL ABSORPTION SYSTEM (SAS):_VES_(locatc on site plan,excavation not required) If.SAS not located explain why: Type _X_leaching pits, number: _one 6' x 6' pit w/2' of stone_ leaching chambers, number: leaching galleries,munber: 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 found>7' deep,no signs of failure. CESSPOOLS: N/A_(cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): *Recommend: Maintenance pumping every 3—5 yrs., PRIVY:_N/A(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.): Page 10 of I 1 OFFICIAL .INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 42 Coachman Lane W. Barnstable_ Owner's Name:_David Foster_ Date of Inspection:_2103A)3_ SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet. Locate where public water supply enters the building. t��Vj � A Q A A - � _ :z� ' � C. 13 O � P,igc I I of I 1 OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 42 Coachman Lane W. Barnstable_ Owner's Name:_David Foster_ Date of Inspection:_2A)3103_ SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water_24 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) _X_Accessed USGS database-explain: Yo-.i must describe how you established the high ground water elevation: By U.S.G.S. atlas H A—6 9 2 140 03 0- — I tc?" Lo. Ilk 19 oMp°q°!�0°A//ap.ao * a • ! 9 x c')q ppalf •'1 CHUCJ vaa• 1 T PLAN "AS BUIL PLOT TO THE BEST OF MY INFORMATION, 4��5 � � MASS. KNOWLEDGE, AND 8ELIEI~ THE L�,� 3Z5`- '0� .-6 SHOWN ON THIS PLAN HAS BEAN "' n THE R c% l kEARII/ //1/�; =r?s� SWAN RIVER PLAYA GROUND AS INDICA`t., !:� t 5 ROUTE 134, UNIT 2 .n SOUTH DENNIS, MASS. 02660 DATE SCALE J. JOIN NO. D TE REGISTERE LANC�';)t RVEYOR nz� ��v. lcucr--Ti nc � !; 400� TROY WILLIAMS It SEPTIC INSPECTIONS N Certified by MA Department of Environmental Protection 6j I 'ta41 ► (508) 760-1819 40 Old Bass River Road F South Dennis,MA 02660 c "''>.J 00 Co�weam, Of Massachusetts Executive Office of Err�rorxnertial Affairs (COPY Department of • Environmental Protection Witham F.W*ld Ooiwrnor t- Dtrvlda�trtrha SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: p Coe,-, ►+ -% LH WC s)L A?--s ti-6 A_ Address of Owner: �� �.M d �r;S W o.-f-S o�• Date of Inspection: 16/a 6 /�(f— Of different) Name of Inspector: �/ra (nl, 1%N N•> S 0."^ Company Name,Address and Telephone Number: se-- n6o _.t. CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of 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 Inspector's Signature: Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority 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 the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B,C,or D: A) SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. BJ SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If'not determined', explain why not) The septic tank is metal,eradced, structurally unsound, shows substantial infiltration or exfihration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. trw Lsed I/tS/95t 1 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 9.2 C o 1,.,�.�a Owner: W Date of Inspection: /a �2 6 Ai, s B) SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution 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 replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed 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 the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _. Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM 15 FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: — The cv5tem has a septic tank ana soli absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. — The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. _. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 PPm• DJ SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. _. Backup of sewage into facility or system component due to an 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. revised 8/15/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: V.? C�a�!,•�-a Owner. (nJ S o h Date of Inspection: la /z e 9 s D] SYSTEM FAILS(continued): Static liquid level in the distribution box above outlet invert due to an overloaded or dogged SAS or cesspool. Liquid depth in cesspool is less than 6' below invert or available volume is less than 1/2 day.flow. Required pumping more than 4 times in the last year NOT due to dogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a 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 I 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The design flow of system is 10,000 gpd or greater(Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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 11 of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 6/15/95) 3 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKUST Property Address: 1/01 Owner. WC,�-So" Date of Inspection: Ch edk'if the followinghave n been done: ,/Pumping information was requested of the owner, occupant, and Board of Health. ,None of the system components have been pumped for at least two weeks and the system has been receiving normal 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 an mi if h are not available with WA 1L p d examined. Note they e Y The facility or dwelling was inspected for signs of sewage back-up. ,/The system does not receive non-sanitary or industrial waste flow ZThe site was inspected for signs of breakout. ✓All system components, excluding the Soil Absorption System, have been located on the site. ZThe 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 on the site has been determined based on existing information or approximated by non-intrusive methods. _✓The facility owe, (and occupants, if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. Irevlaed 8/15195, 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner: Date of Inspectional FLOW CONDITIONS RESIDENTIAL: Design flow:-93 6 gallons Number of bedrooms: -1 Number of current residents: o? Garbage grinder(yes or no):No Laundry connected to system (yes or no): YES Seasonal use (yes or no):/,/° Water meter readings, if available: Last date of occupancy:jO C c—ulo;e eA COMMERCIAUINDUSTRIAL: ".im Type of establishment: Design flow:- allons/day Grease trap present: (yes or no)_ industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: —' OTHER: (Describe) Last date of:occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: /�l�--F?"&'tn . '4,K5 iG✓'-.y✓ p<i fD O��al"rneo! 7�'nc.. �OKc Jv+tiG� System pumped as part of inspection: (yes or no)�/o If yes, volume pumped. Qallons 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) Other (explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: �s fu,/��c! 5//7/S'6 �✓ CAS— Lek 0. Sewage odo-rs detected when arriving at the site: (yes or no) (revised 8/15/951 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: C #I-a ti Owner: INU-1-3 0 Date of Inspection: SEPTIC TANK: (locate on site plan) Depth below grade: 3 s r%s cr. w;rz:, Material of construction: concrete _metal _FRP —other(explain) Dimensions: S )e'T 1,t- 6 /oo0 S l udge depth: S Distance from top of sludge to bottom of outlet tee or baffle:_/ 11/0�' Scum thickness: 9" Distance from top of scum to top of outlet tee or baffle: 3,, Distance from bottom of scum to bottom of outlet tee or baffle: re Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, strtictural`� integrity, evidence of leakage, etc.) Lis �.,.1 �t ;�, ,,�ar o r.A w ^/., S;;r. t ; 0 7C /n ,S A]­'j AW/'H s! G�4✓r�ac.c_ / u0, Aj C- O N.- A.- GREASE TRAP:/'l (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP —other(explain) Dimensions: scum thickness: Distance from top of scum to top of outlet tee or baffle: `11stance from bottom r%i cro— t^ honnm of ou?jet tee o, banie- Comments: ,recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) ,revised 8/1S/9S1 6 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: y4 <-o Owner. W,-+."o Date of Inspection: TIGHT OR HOLDING TANK:.LV�i9 (locate on site plan) Depth below grade: Material of construction: concrete_metal_FRP other(explain) Dimensions: Capacity. gallons Design flow: ¢allons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: le-1-d Comments: note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) '07/5-i- Was /tv�( «.. r °�. r,.>cSv ft, r„ ordc.i PUMP CHAMBER: (locate on site plan) Pumps in working order.(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 8/15/95) 7 r SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM '9 PART C SYSTEM INFORMATION (continued) Property Address: 112, Lo ct Owner. Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type. / leaching pits, number: 6 �l-d ��,c� C,ri*4- w tQ S y4o L-L t. leaching chambers, number:_ leaching galleries, number. leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condi ion of vegetation,etc.) Ii� s o : 4V, �7C �, ucJ( L .: � ✓✓ -t veb - i CESSPOOLS: Nlq (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 (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: / /11 (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.) (revised B/15/95) $ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: yA Owner. Date of 1 nspection: � SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' 3y ay/ b� DEPTH TO GROUNDWATER Depth to groundwater: — feet adjusted high groundwater level method of determination or approximation:�S G l�rv� of „✓� �w P'-,—b A c � o � L, a (revised 6/1.S/95) 9 �- TOWN OF BARNSTABLE I;AJCfi.T'^N y� CD SEWAGE # V1`�LAGE ASSESSOR'S MAP&LOT I S 2 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY d vy LEACHING FACILITY: (type) (size) NO.OF BEDROOMS 3 BUILDER OR OWNER PERMTTDATE: y/ ? /,Y4 COMPLIANCE DATE: 9'1a'2 C Separation Distance Between the: fS--- Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by e' 1 G e,K,a l zy ' fl 3q (dt N. 7� r . I. 0CATIO,N SEWAGE PERMIT NO. Lo -C 4- Cif ZW J1ILLAGE Hse INSTALLER'S NAME A ADDRESS S UILDER OR OWNER DATE PERMIT ISSUED �/,7/dz6 D A T E COMPLIANCE ISSUED 8' �o C�..��e.����A.► dam. No._�3 =...D 6 S F$ ..... �� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Appliration for Digpasal Works Ton.strurtion Permit Application is hereby made for a Permit to Construct (6-)/or Repair ( ) an Individual Sewage Disposal System at, j �� ................______..... ......... .................................-- ..... __.........._...... -- .... -------•-••---........_..__.__.... Loe ti n-Address ............................................Lot No. ............_�� _..R.t:�_ ... 1�:. 1 n/...... -. .T _......................... W A Owner �v� / } Address .................f .U....V... ........ ........�.........T..........'f..0.(.... ................. .......---......_..... Installer Address / �/ Type of Building Size Lot.......f................Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder (-')0 `4 Other—Type e of Building ....... No, of persons........................... Showers G� YP g --------•----....-•-- P ( ) — Cafeteria ( ) 04 Other fixtures W Design Flow................................// ....gallons percPepsow�e; day. Total daily fl9w............ .......-_._-................gal,p/. WSeptic Tank—Liquid capacityl...........gallons Length..�.Z..... Width. ........... Diameter................ Depth- 57.......... x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No............(......,,Diameter.......�.2... Depth below inlet................. Total leaching area-_7 -2_...sq. ft. Z Other Distribution box ( ") Dosing ) Percolation Test Results Performed by....................y..�......................... . ... .' D'atte.._........... ......._�.._... ,.1 Test Pit No. 1.....'6___.. minutes per inch Depth of Test Pit.....1............ Depth to ground water....7--. _..?_....-. f=, Test Pit No. 2...............minutes per inch Depth of Test Pit...f.z _. .. Depth to ground water...7.1 Z........ a Description of Soil. 7......... .... �'•'�_--_-_--•--••-•-•--• ...... V 6 z L..7�.P- ............................. �Sl...�tcrs?C ................................. .......................................... . ..._..................................... W UNature of Repairs or Alterations—Answer when applicable............................................................................................... -------------------------------------------•-•----.......-•--•-.....................----.............................-------•-•-•---•-•-----................----....._...--••---•--•-------....._... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the rovisioiis of TIT 5 of the State Sanitary Code—The undersigned further agrees not to place the system in o ation ntil a C, sate of Compliance has been ' by the board of healjh. uigned... R.3•..--- .. a..�... .....Ss ......................... ...........- . ..._.... Date A lication Approved By--....... ..........................._ ........I .....�.�.� .. ............ Date Application Disapproved fort ollowing reasons:............................•__..___......_......_.........._......__._.............. _....................................................••--•---------......:_•----...---._.....----...._................................................_............................................- Due PermitNo..................................._.._...._.......... Issued..-........-••_. .........---._...... ............. Dace P _ _ _r No_' Fini _ THE COMMONWEALTH OF MASSACHUSETTS fi BOARD OF HEALTH J . saf 4 . .' ... ....................OF........ s'�i'1 .�/.rg.�c Applirtttion for Disposal Works Tonstrnrtion ramit Application is hereby made for a Permit to Construct �or Repair ( ) an Individual Sewage Disposal System at, .........................». �t »t.;�F`l;�-4,) . �-�,J.�'..........».--•...... ......................»».........-•-... `` Location Aa5 of of N - C . 1� :. ....... .... °..»....._.............................».»........_._._...___........'. a ## Owaer� �n V .' Address .............••...?rt:...........».........,............................... ............... ............ Installer Address Type of Building Size Lot..<5...1a 5�7 .Sq. feet .� Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder 04 Other—Type T e of Building No. of persons............................ Showers — ' w YP g •..........................• P ( :) Cafeteria 04 Other•fixtures ..............�..-••---._...--•---s�;,•�-�,• � • .�' - - ' d ..��........................... ........ W Design Flow....... gallons per persorr per day. Total daily flow......................................... gallons. W Septic Tank—Li uid capacity lops Len .. Width.. _.'` _... Diameter................ Depth.'.'.'.............. P q P ty.y......-t;, gth........ x Disposal Trench—No. ......? ......._.. Width.................... Total Length............._...... Total leaching area...................sq. ft. 3 Seepage Pit No........... ........ Diameter........L"2 .. Depth below inlet........Z5...... Total leaching area...=�....sq. ft. Z Other Distribution box ( Dosing tank1.4 Percolation Test Results Performed by... ........................ ...................,..._... Date.............. -........... a Test Pit No. 1.....! ......minutes per inch Depth of Test Pit.....1........... Depth to ground water...�- ........ 4 Test Pit No. 2..... .......minutes per inch Depth of Test Pit_..: .7':..".. Depth to ground water..7./ ?........ W .............................. .........................�............. ......................�... O Description of Soil...Q..:: ? T`...'� f v S'©� /k' -... .......................... ..... ..................--••-----............_............................_......--------••- ►�+ /S—ZY 7 r� 7��!i l�Sa iC Z.S-- / V9 ��c �/ tde. i .� IX' —'P -7��"i.���_ W. ..... --•..........<d ............. --- ..------ -----......-.-..---..----•--••------.-•------.--•--------------............ ^•• ...... ....... ....................•............_.......•----.........................•---_.......................................•........•.......•-••--.............•--••••-•........................................ 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 TIT 5 of the State Sanitary Code—The undersigned further agrees not to place the system in ` o tion ntil a C sate of Compliance has by the board of healL�'►. .. igned... .. �...••-- ......, ......:�...............•--........ ---._...-•----............».... Ap lication Approved B Date y......... ........ . ... .: . Date Application Disapproved for th f llouwing reasons:...................................................................... ......!::t. ..Y.?_...»»» PermitNo.................................._..........._..».... Issued..-............ ... :.::...._ THE COMMONWEALTH OF MASSACHUSETTS ��1 BOARD OF HEALTH a t.� 1 ! . v............t•P.W.J... ..OF...... >3�i.1{� `t9y3L .. ............. 4� k _ farrtif irat a of Tomplilawr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (�e) or Repaired ) ► 11!h by �1 y"1. .Y .!y�£... . '`^� Installer at ............:..................4 0...... 4.......... ......� has been installed in accordance with the provisions of TITiF 5 of The State Sanitary Cod as escribed in the application for Disposal Works Construction Permit No.._..._..�.-__..'LO�tS._... dated_.......�!. ._�S.... 5................ THE ISSUANCE OF THIS. CERTIFICATE SHALL NOT BE CONSTRUED AS A GUA AN EE THAT THE N=SYSTEM W L FUN�TIONySATISFACTORY. DATE.:......... ......f56 '.------..'. w . ---•-:......... Inspector......��.................•--•-•...... --••-•------•^ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF, HEALTH , ~OF No...... ................. FEE ......_............. Disposal ors Tonstr nkjermitPermission is hereby granted.............. �r..!.. `CI rVST .................. -••••---•-••••.............».... to Construct ( •) or Reppaa��•r ( ) an Individual Sew.Disposal System lat No. ........ ...................__.... C.� .. .._:» ! Itz..---•••••..��..... Street 3 1 tt as shown on the application for Disposal Works Construction—Per No at_ed_. ........................ ............... 'B . of Healt - ,�DATE ....... ......................................... � :.._. FORM 1233 HOB139 8 WARREN. INC., PUBLISHERS ^:�,l.,l 7• j, .r - i 2Q FT MfN. d # '"OP OF FOUND I EL — I i FT MIN. h L.' - M1� CONCRETE 4 SCH. 40 PVC - _--._CLEAN SAND `~ 1 COVERS PIPE MIN, PITCH 1 5 1/8`d PER fT: CONCRETE" I =l lei —___ COVER I 4" CAST IRON ? LAYER OF i < PIPE - MIN. PITCf' I2 MAX. ll6t' �G ,f WASHED d t I/4 PER FT 1 } STC7N h LINE s - :FLOW E � °" j w _ a EL MIN. EL EL.= EL - - EL,-- DI S T E . y, LOCATION MAP BOX a 1 WASHED STONE ' b � L p o`r,° A U , w C° 0 C7lIL.` PRECAST LEACHING °°vGl EL.= , BASIN OR EQUIV: SEPTC TANK : BOTTOM OF TEST HQt�F OR USES PROBABLE WATER TABLE EL, PROFILE OF - - GROUND WATER TABLE( / / EL. = SEWAGE DISPOSAL SYSTEM t NOT TC SCALE 4 DESIGN CALCULATIONS e - - SOIL TEST NLIMBER OF BEDROOMS .. . . . .- . ^1 . . . DATE OF SOIL TEST GARBAGE DISPOSAL UNIT_ _. _ _ _ _ - . - NITNESS-ED BY — TOTAL ESTIMATED FLOW r, + Gfi,i_ .`CAY PER OLAT ,GN RAT E — MIN./INCH GAL /BR./DAY x 8R, ) _ � OBSERVATION HOLE 0 SE ATION HOLE 2 REQUIRED SEPTIC TANK CAPACITY.... .. ... GAL. E OF 5ETC AN ELEVATION ; /:-F'LEVATIONACTUAL _ rA` LEACHING AREA REQUIREMENT5 w _ _ S IDEWALL APEA L __^._ a GAL S.r v BOTTOM AREA = ,Y GAL./S.F. , t 1 H APACi' �" ( OTT OM � IDEWA` _ GAL t -- A _EAC ING C BO C S � L� s : a f r R't a HIN CAPACITY...:. .-. GAL. cc �v .E G 1 4 , ti , NOTES �- I. ALL WORKMANSHIP AND MATERIALS SHALL CONFORM w.. TITLE S AND THE TOWN OF TO D.E.Q. %:�{ . ; .-,...._- '�. - M1 RULES AND REGULATIONS FOR SUBSURFACE DISPOSAL L OF SANITARY SEWAGE 2. ALL COVERS TO SANITARY UNITS SHALL BE BROUGHT TO t WITHIN 12" OF FINISHED GRADE. 3. EXISTING AND FINAL GRADES SHALL REMAIN ESSENTIALLY MIN. FRONT SETBACK THE SAME. MIN. REAR SETBACK 4. NO DETERMINATION HAS BEEN MADE BY THIS OFFICE AS TO MIN, SIDE SETBACK -` F r c� I WITH TOWN ZONING REGULATIONS. OWNER/APPLICANT COMPLIANCE T 0 k L r Y APPROVED :, BOARD OF HEALTH IS TO OBTAIN SUCH DETERMINATION FROM! APPROPRIATE AUTNORITf ._ - DATE AGENT PROJECT LOCATION: F , i y _ a .fi APPLICANT : fyJ y\ y s . f , �F scALE p e DATE: ,. LEGEND , - ,`, .EXISTING . SPOT ELEVATIONS- OO O rra :' J©B NQ -,,. APPO. BY; REV. t E - XISTING CONTOUR - - - OO- - - - ',rAE E ' FINAL SPOT ELEVATIONS OO.O .- f ,, N bra FINAL CONTOUR 't ;;3, R. J. O HE,4R 1, INC. DRAWING — SOIL TEST LOCATION „ r 'a REG. LAND SURV YQRS- REG, SANIrAR/ANS SITE -- LA N O. 35ourE �34 -- — EINiT ,2 SOUTq.DENNLS , MA5S. OF L