Loading...
HomeMy WebLinkAbout0050 CURRYCOMB CIRCLE - Health 50 CURRY COMB CIRCLE, W. BARNSTABLE A = �5�- . r 4 DATE:-10/15/99 PROPERTY ADDRESS: 5Q .CurrY_Comb_Circle ___ --West Barnstable ,Mass____ 02668 ------------------------ 01 �. On the above date, I Inspected the septic system at the above address. This system consists of the following: 12 >> 1 1 . 1-1000 gallon septic tank. 2 . 1-1000 gallon precast leaching pit . Based on my Inspection, I certify the following co i IOIQ,r.T 1 9 1999 w 3 . This is a title five septic system. ( 78 Code T=OFBAMnft 4. The septic system is in proper working order (� at the present time . 5 . Pumped septic tank at time of inspection. 4p� r r SIGNATURE: r,,------ Company: J e.2h_P . Maco.mber_& Son , Inc . Address:- Box 66 ------------------- Centerville , Ma . 02632-0066 -------------------- Phone: 508-775-3338 --------------------- THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY L6EiPH P. MACOMBER & SON, INC. anks Cesspools•LeachfleIds Pumped & Installed Town Sewer Connectlons 66 Centerville, MA 02632-0066 775.3338 775.6412 4, COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292.5500 • I I TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B. STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 50 Curry Comb C i r c l r Name of Owner M a r y Macomber West Barnstable ,Mass . 02668 Address of Owner: Data of Inspection: 10/15/9 0 Name of Inspector:(Please Print) Joseph P.Macomber Jr . I am a DEP approved system inspector pursuant to Section 15.340 of True 5(310 CMR 15.000) Company Name: J. P.Macomber & Son T n c - MaiLng Address: 02632 Tallaphonellilumbef:b08-175-3338 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: /V� Date: The System Inspec r all 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 otrEnvkonmental Protection. The original should'be.sent toviv system owner and,copies sent to the buyer, if applicable, and the approving authority. . NOTES AND COMMENTS revised 9/2/98 Pagel of11 LJ Primed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (aorttirsued) P,opertyAckk"4: 50 Curry Comb Circle West Barnstable ,Mass . Owner: Mary Macomber Dane of Lwoctiort: 10/15/9 9 INSPECTION SUMMARY: Ctwck A, B, C, of D: 3 A. SYSTEM PASSES: I have not found any Information which Indicates that any of the failure condltions described In 310 CMR 16.303 exist. Any failure criteria not ovahuted are Indicated below. COMMENTS: B. SYSTEM CONDITIONALLY PASSES: One or more system components as described In the 'Conditional Pass' sacdon need to be replaced or repaired. The system, upon complation of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes,.no, or not determined(Y. N, or NO). Describe basis of determination In all Instances. If 'not determined', explain why not. The septic tank Is metal, unless the owner or operator has provided the system Inspector with a copy of a Certificate of Compliance (attached)Indicating that the tank was Installed within twenty(20) years prior to the date of the Inspection; or the septic tank, whether or not metal,Is cracked, structurally unsound, shows substantial inliitratlon or exfiltration, or tank failure Is Imminent. The system will pass Inspection If the existing septic tank Is replaced with a complying septic tank as approved by the Board of Health. / Sewage backup or breakout or high static water level observed In the distribution box Is due to broken or obstructed pips(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 pips(s) are replaced obstruction is removed distribution box Is levelled or replaced - The system required pumphtg•mon thawfourtimes t+•yeardus to broken or obstructed pipe(s). The ryrtrm wi(IyesT^ Inspection If(with approval of the Board of Hsaith): - broken pipes) are'►eplaced obstruction Is removed revised 9/2/98 Page 2of11 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 50 Curry Comb Circle West Barnstable ,Mass . owner: Mary Macomber Daft of Inspection: 10/15/9 9 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 IN ACCORDANCE WiTH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICKYVILLP80TECT THE PUBLIC HEALTILAND SAFETY AND THE ENVIRONMENT_ �b Cesspool or privy is within 50 feet of surface water 40 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 AND SAFETY AND THE ENVIRONMENT: AO 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 soil absorption system and the SAS is within a Zone 1 of a public water supply well. The system has a septic tank and soil absorption system and the SAS Is within 60 feet of a private water supply well. _ The system has a septic tank and soil absorption system and the SAS 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. Method used to determine distance If)A _(approximation not valid).- 3) OTHER revised 9/2/98 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTiON FORM PART A CERTIFICATION(continued) Property Address: 50 Curry Comb Circle West Barnstable ,Mass . Owner: Mary Macomber Date of Inspection: 1 0/1 5/9 9 D. SYSTEM FAILS: You must indicate either "Yes' or"No" to each of the following: I have determined that one or more of the following failure conditions exist as described 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. Yes No _ 1-"' Backup of sewage into fecilityor•-o"tem component due tto an overloaded orclegged'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.ceeepool 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 clogged 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 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. 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: 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: The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system 13 a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No / the system Is within 400 feet of a surface drinking water supply the system•ls•witWo 200 teetota t+�butar oasurtaoadrinkir�gawtersupply•••• - __... _. _ ._ 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 upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further inforptation. i revised 9/2/98 Page 4of11 i i 1 i jSUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM � PART B n CHECKLIST PropertyAckit s: 50 Curry .Comb Cir•dle West Barnstable ,Mass . Owner: Mary Macomber DoW of Inspection: 10/15/9 9 Check If the following have been done: You must Indicate either "Yes" or "No" as to each of the following: Yes No Pumping Information was provided by the owner, occupant, or Board of Health. _ f None of the systemcompoa&nis.bauaJimart sad-tbe'system hssbaeovscalakagwon"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,eluding the Soil 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 f distance is unacceptable) / 115.302(3)(b)) 4 _ _ The facility owner.(and.ocr,,pant,,Jf dif araW flpGlplp(IIer�.3K81g plL]Ljlfgdyy(S}�Ininrmnti pry fhn p.ppor�AintnnnM 'f SubSurface Disposal Systems. i i , i" i revised 9/2/98 page sorn SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMA71ON PropenyAddrsss:50 Curry Comb Circle West Barnstable ,Mass . Owner: Mary Macomber Date of I"sDe1'10/15/9 9 FLOW CONDITIONS RESIDENTIAL: Design flow: !ID g.p.d./bedro m. Number of bedrooms(design Number of bedrooms(actual): Total DESIGN flow n ,, Number of current residents Garbage grinder(yes or no):_ Laundry(separate system) ( sa 0 n ):_', if yes, sepawaInspectlon.required --. Laundry system Inspected yes r no) Seasonal use(yes or no): -7� Water meter 4 readings,If available(last two year's usage(gpd): i r Sump Pump(yes or no):-12,P ` �--but�j .. Last date of occupancy• COMMERCIALANDUSTRIAL: Type of establishment: Design flow: o(IA sapd ( Based on 16.203) Basis of design flow Aw Grease trap present:(yea or no) Industrial Waste Holding Tank present: (yes or no)-a-14 Non-sanitary waste discharged to the Title 6 system: (yes or no)ZI!9 - Water meter readings,If available: Last date of occupancy: A/4 OTHER:(Describe) 44 Last date of occupancy: GENERAL INFORMATION PUMPWG R 7'CORDS -��guAce�yfPinformation: � �j System pumped as part of Inspection: (yes or no) e if yes,volume pumped: In ns R Reason for pumping: i YSTEM eptic tank/distribution box/soil absorption system ingle cesspool verflow cesspool rivy hared system(yes or no) (if yes, attach previous Inspection records,if any) A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank fle4 Copy of DEP Approval Other APPAQ*LMATE AGE of all components, date InstaNed{if known)-and Bourse of4oformation: ` odors d Sewale o hen•arriving at the site: (yes or no)_ revised 9/2/98 Page 6of11 LOCATION r4— SEWAGE PERMIT NO. �—o "V G I P,cL,/ q 5 VILLAGE INSTA LLER'S NAME L ADDRESS n� B UILDER OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED 2 �'l O u li SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ^' PART C , e SYSTEM INFORMATION(continued) Property Address: 50 Curry Comb Circle ,West Barnstable ,Mass . Owner: Mary Macomber Data of Inspection' 10/15/9 9 BUILDING SEWER: (Locate on site plan) Depth below grade: Material of construction:_Ycast Iron t/40 PVCV54 other(explain) .UJQ Distance fromprivate water supply well or suction line 10 17- Diameter Comments: (condition of joints, venting, evidence of faakage,-etc.) Joints appear tight - Nn avi di-nra of 1 inaka e SEIPITIC TANK: (locate on site plan) X Depth below grade: Materiel of construction: concrete,f/�metaUl�Fiberglass,Iri�Poljrethylene(1/�other(explain) If tank Is Fnetal,`'list age Js.age.confirmedby Certificate of Compliance!U (Yes/No) c Dimensions:/G� CA,f.I: �' N�� � Sludge depth: Distance from top of ludge to bottom of outlet tee ortaffie Scum thickness: !� Distance from top of scum to top of outlet tee or baffler Distance from bottom of scum to botto of o e tee or baffle How dimensions were determined: Comments: (recommendation for pumping,condition of inlet and outlet tees or-baffles, depth of liquid level in relation to outlet invert, structureHintegrity, evidence of leakage,etc.) Pump tank every 2-3 years +Inlet P, ou 1 t tPPG n^TP in i 1 nrP ThP tank is stcuctur-ally sguil- s1}d- shows He evideRee GREASE TRAP: (locate on site plan) Depth below grade:�� Material of constructionW- 4concret%4metaW0 Fiberglas&V,4 Polyethyleneother(explain) Dimensions Scum thickness: Distance from top of scum to top of outlet tee or baffler Distance from bottom of ac m to bottom of outlet tee or baffle: 4/# Date of last pumping:_� 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.) rease trap is not present Page p revised 9/2/98 Ps e SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) PropertyAddress:50 Curry Comb Circle West Barnstable ,Mass Owner: Mary Macomber Date of Inspection: 10/15/9 9 TIGHT OR HOLDING TANK-4&&(Tank must be pumped prior to, or at time of,inspection) (locate on site plan) Depth below grade: xJ4 Material of construction.,concreteM.metaW,4Fiberglas&#,4Polyethylene4tAother(explain) Dimensions: Capacity: d& gallons Design flow: gallons/day Alarm present Alarm level: Alarm i- Al working order:Yes�Q No-V1 Date of previous pumping: Comments: (condition of Inlet tee, condition of alarm and float switches,etc.) Tight or holding tanks are not present - DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: Comments: (note-if level and distribution is equal, evidenoe of solids carryover, evidence of leakage Into or out of box, etc.) —Distribution bnx hag nna lateral No evidence of solidg sal^r-y gvel• . Nn e- irlence of leafage 14te 9£ out e€ to—be PUMP CHAMBER:_�40(? (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.) uMD chamber is not prFGPnt _ revised 9/2/98 Page 8ofII e ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .1 PART C " SYSTEM WFORMATION(continued) Prop*MAddress: 50 Curry Comb Circle West Barnstable ,Mass . Owf1 : Mary Macomber Dsu of Inspection:10/15/9 9 SOIL ABSORPTION SYSTEM(SAS):_ (locate on site plan,if possible; excavation not required,location may be approximated by non-Intrusive methods) If not located, explain: Type: J leaching pits,number: leaching chambers, number:15 leaching galleries,number:, leaching trenches, number, length: leaching flelds, number, dlme &Ions: cvarflow casspooi,number: Altsrnadve system: Name of Technology: Y Comments: Inots condition of soil, signs of hydraulic failure,level of ponding, damp soil, condition of vegetation, etc.) Ioamy sand to riny to -c1esp sandeNe 84:8118 Oi hydraulic ow trie invert pipe . age a ion is normal , CESSPOOLS: flocate on slit plan) Number and configuration: Depth-top of liquid to inlet Invert: Depth of solids layer: Depth of scum lays[. Dimensloh's of cesspool: Matarials of construction: Indication of groundwater: Inflow (cesspool must be pumped as part of Inspection) Cesspools are not present _ Comments: (note condition of soil, signs of hydraulic failure,.level of ponding,condition of-vegetation, etc.) Ce44=onl c arms nInt- pr@g9ate PRf Vy Ab)e (locate on site plan) ,Q Matarjals of constru tlgn: Dimensions: Depth of aolids: Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation;etc.) Privy JQ not racont r revised 9/2/98 Page 9of11 -• SUBSURFACE SEWAGE DISPOSAL SYSTEM tNSPEC'nON FORM PART C SYSTem tNFORmATION fcoff rx►aCI ft0p*nYAddras: 50 �Cur>y Comb Circle West Barnstable ,Mass . Dw^'r' Mary Macombor Dfu of tr►ap.r.ts«+. 10/15/9 9 SKETCH OF SEWA GE DISPOSAL SYSTEU: . Includs ties to at Fast two psrm&nsnt relersnce landmarks or benchmarks local# all wells wlLWn 100'(locate wham publlo water supply comas Into house) LOT I you— ,. .� • �►a r a o a`� a�3+ - `l revised 9/2/98 Page looell 1699—SZ� �uvdmo0 je, >vK ' sTTTY1 suo, sSJVK OTTTAJ9,,80 eTTTn.ze�ue0 0 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ,_ u SYSTEM INFORMATION(continued) PropertyAddresa: 50 Curry Comb Circle West Barnstable ,Mass . owner: Mary Macomber Date of UuPscticn:10/15/9 9 NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep _ SITE EXAM Slope Surface water Check Cellar Shallow wells I Estimated Depth to Groundwater Feet Please Indicate all the methods used to determine High Groundwater Elevation: �btained from Design Plans on record I/Observed.Site(Abutting prop![ bservation hole, basement sump etc.) determined from local conditions Checked with local Board of health Checked FEMA Maps ­L/Checked pumping records Checked local excavators,Installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) Used water contours map . Gahrety & Miller Model 12/16/94 revised 9/2/98 Page 11of11 •„wnr�.-n rrsr�tr- rwrmr•nn.r.r�.�,�rrrnnn+,+e�n►iew+�.vrm+Rrw•a.n�en w•A TOWN OF Barnstable BOARD OF HEALTH SUDS•'•TPI�T•:•t1t—T,,„�,TT,.m UIIFACF SEWAGE (,i I'USA L�SY�3TEM I�N9PF�CI'ION FORM - PART D •- CERTIFICATION J nr,,,n •rV"T•Yr„�•• -TYPE OR PRINT CLEARLY- PROPERTY INSPECTED STREET ADDRESS 50 Curry Comb Circle West Barnstable ,Mass . ASSESSORS MAP, BLOCK AND PARCEL # I S" (C) Z OWNER' s NAME Mary Macomber • PART D - CERTIFICATION NAME OF INSPECTOR Joseph P.Macomber Jr . COMPANY NAME J.P.Macomber & Sag1* 7nc . COMPANY ADDRESS Box •66 Centerville ,Mass . 02632. Stregt Town or City 9tat• LIP COMPANY TELEPHONE (508 ) 775 - 3338 FAX ( 508 ) 790 - 1578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate , and omplete as of the time of ,inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent With my training and experience in the proper function and maintenance of on- site sewage disposal systems , • ' % IIiVi Ch^ecck one: /� System PASSED ; The inspection which I have conducted has not found any information winch indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 16 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. System FAILED* The inspection which I have con cted has found that the system fails to protect the public he•itlth and the environment in accordance with Title 5 , 310 CMR 15 - 303 , and as specifically noted on PART C - FAILURE CRITERIA of this Inspection form , Inspector Signature - Date Dnfie coDy of this ce tication must be provided to the OWNER, the BUYER where applioable) and the I30ARD OF HEALTH, * If the inspection FAILED, the owner or.""operator shall u d within obe year of the date of the inspection, unless allowed ortrequiredm otherwise as provided in 3.10 Ch(R 16 , 306 , partd.doc Commonwealth of Massachusetts i Executive Office of Environmental Affairs ' Department of environmental Protection Trudy Coxe = David B. Struhs U.Go"fly CamrNss�r • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION property Address: 50 Curry Comb Circle West Barns tabdlk of owner. Date of Inspection: 0/ 8/96 (If different) Name of ln,pector:Joseph P.Macomber Jr. Company Name,Address and Telephone Number. J.P.Macomber & Son Inc. Box 66 Centerville ,Mass . 02632 508-775-3338 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-sits sewage disposal systems. The system: , Passes Conditionally Passes — Needs Further Evaluation By the Local Approving Authority _ Fails / Inspector's Signature: ' " Date: 1'�'4- y`�6 1 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of�co�mpleting-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 submits report to the appropriate regional office of the Department of Environmental Protaction. The original should be sent to the system owner.wd copies sent to the buyer, if applicable and the approving autho'ty" Noy ufi(r® INSPECTION SUMMARY: �--, 3 Check A, B. C, or D: `p' g A) SYSTEM PASSES: have not found any information which indicates that the system violates any of the failure criteria as definPin91-_Cb1R 15?303:'4� Any failure criteria not evaluated are indicated below. — r� B) 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 yeail�, or not determined(Y, N,or ND). Describe basis of determination in all instances. If"not determined", explain why not) �C The septic tank is metal, cra:ked, structurally unsound, shows substantial infiltration or ezfUtration,.or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a ponforming septic tank as approved by th. Board of Health. (revised 11/03/95) 1 One Winter Street • Boston, Massachusetts 02108 • FAX(617)556-1049 a Telephone (617)292.5500 Printed on R"Ied Paper } SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (oontinued) Property Add 50 Curry Comb Circle West Barnstable ,Mass . Owner. Shirlejt Lajeunesse Date of Inspeotlon: 10/2 8/9 6 B)SYSTEM CONDITIONALLY PASSES(continued) Sewage backup or breakout or h0h static water level observed in the distribution boa is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution boa. 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 .oa The systam 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 pips(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 60 feet of a surface water AZO Cesspool or privy is within 60 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 IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: .0 The system has a septic tank and soil 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 sygtsm and is within a Zone I of a public water supply well. .&10 The system has a septic tank and soil absorption system and is within 60 feet of a private water supply well. The system has a septic tank and soil absorption system and is Is"than 100 feet but 60 feet or.more from a private water ouppl'wall,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 6 ppm. 3) OTHER L' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) PropertyAddresa: 50 Curry Comb Circle West Barnstable,Mass . Owner. Shirley Lajeunesse Date of Inspeotion: 1 0/28,/96 DJ SYSTEM FAILS: e �Il h I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 16.303. 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. A20 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 4istnbution box above outlet invert due to an overloaded or clogged SAS or cesspool. ye Liquid depth in oewpool'is leas than 6"below invert or available volume is less than L12 day flow. QJp Required pumping more than 4 tunes in the last year NOT due to clogged 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. �6 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 60 feet of a private water supply well. N` 0 Any portion of a cesspool or privy is less than 100 feet but greater than 60 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: 1 The system serves a facility with a design flow of 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 �1 the system is within 200 feet of a tributary to a surface drinking water supply IV the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full oompliana with the groundwater treatment program II requirements of 314 CMR 6.00 and 6.00. Please oonnilt the local regional office of the Department for lluther information.. 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 50 Curry Comb Circle west Barnstable ,Mass . OwnOr. Shirley ra j eune ss e Date of Inspection:1 0/2 8/9 6 Check if the following have been done: Pumping information was requested of the owner, occupant, and Board of Health. one 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. built plans have been obtained and examined. Note if they are not available with N/A. ZThe facility or dwelling was inspected for signs of sewage back-up. ZThe�system does not receive non-aaaitary or industrial waste flow The site was inspected for signs of breakout. Zsystem components,.s-acluding the Soil 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. size and location of the Soil Absorption System on the site has been determined based on existing information or Ze rcximated by non-intrusive methods. facility owner(and occupants, if different from owner)were provided with information on P the proper maintenance of Sub. Surface Disposal System. (revised 11/03/95) 4 ffI SUBSUIU'ACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION PropertyAdd,oaa: 50 Currycomb Circle West Barnstable,Mass . Owner. Shirley La j eune s s e Date of Inspouti.n:: 10/28/96 FLOW CONDITIONS RPS I D ENTIAL- Dean aow:__' Number of bedrooms: Number of cuxnnt rwidsnta:a Garbaa-9 grinder(yes or no):,!ye laundry coaaected to rysum (yes or no):A-5 Seasons] use (yea or no):Az Water meter readings, if available: J�,411 < 924 4'j r / � � l e Last date of occupancy;z' '*Q6 COMMF-RCIAL/INDUSTRIA :- Type of asublishntent: IVA/ Daa:gn Dow:�allona/dny Grease trap present: (yea or ao)d)—A Industrial Waste Holding Tank present: (yea or no)A:�o Non sanitary wasto discharged to the Title 5 system: tyes or no)A Water meter readings, if available- 427 Last date of occupancy: /�- OTHER (Describe) po) _ Last date of occupancy: GENERAL INFORMATION PUMPING RECO S d source o trtfonna ion: System pumped as part of inspection. (yes or nol_ II yes, volume pumped: ADD 6 1'(j is ason l / Re for pumping �l i!�> !i/�/ -�' <CL/l�( /1AVej— TYPE OF SYSTEM _,Septic tarWdi:tributioa borJsod ab4orption a)'atem - 1 Ovorflow cv:spwl Privy Shared ry"m (yes or no) (ayes, attach previous inspection records, if any) Other (esplrin) 1 a �d 'APPROXIMATE AG of" components, date u.+uil]u�l (if known) and source of information: _Zy �f I 0 - E W 5 V Sewave odors Matsu-cam SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART G SYSTEM INFORMATION (continued) Property Address: 50 Currycomb Circle West Barnstable ,Mass . Owner: Shirley Lajeunesse Date of Inspection: 10/28, 96 SEPTIC TANK: L&0�44Z v 74W, (locate on site plan) Depth below grade: ., Material of construction: concrete _metal _FRP _other(explain) Dimensions:_ ' ' ! / Sludge depth:_ Distance from top of sludge to bottom of outlet tee or baffle:__ Scum thickness: U Distance from top of scum to top of outlet tee or baffle: _ Distance from bottom of scum to bottom of outlet tee or baffle• Comments: (recommendation for pumping, condition of inlet and outlet tees or baffle. depth of liquid IPvel in relation to outlet invert, structural rity, evidence of leakage, etc.) Pump tank . every 2-� Years i Tank Dumped as Dart-of ' ao��n No. sung of leakagp froTh the seZtic tank. oN repairs nee e a ythe 'present time. T GREASE TRAP. t4tt, (locate on site pian) Depth below grade:; Material of cons(nortion; ncrete _metal _FRP —other(explain) Dimensions Scum thickness._ Distance from top vt scum to top of outlet tee or baffle:—A)g- .`� Distance from bottom nl <rnm in honom of outlet tee or bditle:_426— Comments: (recommendation for pumping, condi—n of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, struaural integrity, evidence of leakage, etc._ Grease trap is not present. s V Irevised 0/15/95) 6 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oontinued) Propertymdre&& 50 Currycomb Circle West Barnstable,Mass . Owner. Shirley La j eune s s e Date of Inspeotlon.1 0/28/96 TIGHT OR HOLDING TANK_!jjb1e- (locau on site plan) e Depth below grade: ti',01L Material of constructionr,A*ncrete_metal_FRP_other(e:plain) - tiA Dimensions: capacity. AIA n1lons Design flow: &jf pllonslday Alarm level:__ comments: (condition of inlet tee,condition of alarm and float switches, etc.) A tight or holding tank is not needed at. this lnr.atinn _ DISTRIBUTION BOX:, (locate on site plan) Depth of liquid level above outlet invert:_ Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of bout,etc.) Did not intrude, Distrihlition 'hnx J .'; t 5.p=ti (- tank thrniigh hnx to the 1 as nhi nn it Chi clred prl og o pumping the septic tank. PUMP CHAMBER:,L/m/e, (locats on site plan) Pump+in working or•der:(yes or Comments: (note condition of pump chamber,condition of amps and appurtenances, etc.) Pump not needed at this pl0cation. (revlsed 1t/03/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) PropertyAddre&a: 50b Curry Comb Circle West Barnstable,Mass . Owner. Shirley La j eune s s e Date of Inspection: 10/2 8/9 6 SOIL ABSORPTION SYSTEM(SAS)-_& D (locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) e � If not determined to be present,explain:- Type: leschi::g per,number: X �/ leaching chambers,number._ leachia galleries,number. leaching trenches,number,length: leaching fields, number,dimensions: overilow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,stc.) See page 9C CESSPOOLS: (locate on site plan) Number and configuration: Depth-top of liquid to We invert: AIA Depth of solids layer: AM Depth of scum layer:_ AV Dimensions of cesspool: JA Materials of construction: JA Indication of groundwater: A inflow(cesspool must be pumped as part of inspection) .4)4 4 Comments: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.) CP.RR=nnl a are not, present at this location. PRIVY:Aj,2j)'e' (locate on site plan) Materials of construction: y 17 Dimensions:- N A Depth of solids: Commants:(note condition of&oil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.) Privy iG no , present at this location. (revised 11/03/95)• g uJ✓ju,,IFACE SEWAGE DISPOSAL SYSTEM INSPECTION .YL)I i PART B SYSTEM INFORMATION continued SKETCH OF SE14AGE E 'SPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all Wells Within 100 ' Centerville Osterville Marstons Mills Water Company 428-6691 DEPTH TO GROUNDWATER -12-1 + depth to groundwater rAthod of determine;ion or approximation: -- - _.,... . :�• _.....yam"'.'- _ LOCATION �,�� SEWAGE PERMIT NO. 1,o � '* \" C��R.GL(= S VILLAGE I � INSTA LLER'S NAME ADDRESS y\ c.k e� nn B U I L D E R OR OWN ER ��e\ Sci ors DATE PERM I T I S S U E D DATE COMPLIANCE ISSUED 7 ( � :r � tis,P �+ o u . . i G� y I� 1 6 000 10 6-1 LoT �� �or.lED - RF G i.ts 5'T'�R pE V�I,oP gE1'k'Sp!�is Ff�o�T Ma�DUT X I SO = 10 ------ WFPLAN LOCUS; LOT 13 Cur coMrs C1Rc" OF Mqs� - csTZ3/�R�JSt' �l..E N1� ARNE ��c ►'t I �..GQ�3B7�o1 I H. r REF: L*T 13 hNNTElZNIa. down cape engineering LA PREPAREDFOR: CIVIL ENGINEERS �, / ` 'REV. IO/alB6 LAND SURVEYORS R ETN LAN` s / 82a lAsi11 SZ. '. SCALE J" - -AU1Y '�8� SECTION - SEWAGE + -LEACH \v -SEPTIC TANK- Z BOX - Z _"2"OF I12TO W" WASHED STONE TOP OF FON min I' cove 133 Z� I IN• OUT- IN• OUT• IN L2GS?G SEPTIC 12q �29,00 130 TANK ELEV. Y I ELEVi2912� 12q_o 'T ELEV. ELEV. ELEV. ELEV. 31 OF* •l'e +.WASHED STONE �211 ov � TEST HOLE LOG p (a(0 �, I Qrl Z-- BEDROOM HOUSE TEST BY WITNESS DESIGN TEST DATE T.H. 2 ' T•N; B � ELEV- DISPOSER DISPOSER QI' ELEV. I�j3, PERC RATE L Z MIN/IN. rb2.7' FLOW RATE 22-0(GAL./DAY) 33� SEPTIC TANK C ` I REO'D SEPTIC TANK SIZE e4 LEACH FACILITY * 1) ■ 3_1_ G/D. D. an SIDE WAL , I \. O) ■ �/D BOTTOM ra e� TO A +� 121 ,01 144 Q�-r USE: olA� LEACHING � tYr r =0 WATER ENCOUNTERED NOTES; (UNLESS OTHERWISE NOTED) � GUADRANGLE MAP MSLU:TAKEN FRAM_- aVAILA13LIE OF 1•DATUM l 1 µ y,MUNICIPAL WATER I L .I 3'PIPE PITCH:µ"PER FOOT ARNE H. G 4.DESIGN LOADING FOR ALL PRE CAgT UNITS+AASHO'�� 46 OJALA -+ S.MIN.GROUNDSHALL BE MADE WATERTIGHT L SEWAGE CILITIES+ll) . CI'4IL Is ��jOINTS RUCTION DETAILS TO BE ACCORDANCE WITH COMM.Of MASS- 7.CONST STATE ENVIRONMENTAL CODE TITLE S - L,��` �r'2►�+�.►G. A?-J D R NOIN E . A l-1. V esSV�-CD t .0 BOARD OF HEALTH MA OATEN---- •• APPROVED CONTOURS �pRoPOISED)-0-0-0--0- z w � b Lin Sb►yY 3r�1 , _.__ THE _:C.OMMONWEALTH .OF MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION BE IT KNOWN THAT Joseph P. Macomber, Jr. 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. June 8, 1995 Acting Director of the ion of Water Pollution Control '1'ONN OF Barnstable BOARD OF HEALTHr�_ t I SUBSURFACE SENA(;E DISPOSAL SYSTEM INSPFCTION FORM - PART D .- CERTIFICATION l I`..._..._•r••.-: --.v:z^-.r.r-•r:-:.:-r.-c.--n.•-••v••�:.--o-r-r-z-.-.rterrr-rrrsrrsrxrs--rsrrratrsnrrnrr. irrrrrrr-r.-rr- r - ._. -TYPE OR PRINT CLEARLY- PROPERTY INSPECTED STREET ADDRESS 50 Curry Comb Circle West Barnstable,Mass . ASSESSORS MAP , BLOCK AND PARCEL 0 OwNER' s NAME Shirley Lajeunesse PAI?7' D - CenTIFICATION i NAME OF INSPECTOR Joseph P.Macomber Jr. COMPANY NAME J.P.Macomber & So-n Inc. COMPANY ADDRESS Box 66 Centerville,Mass . 02632 Street Town or City State LIP COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( 790 ) 505 - 1578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate , and complete as of the ti.m' e of .inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one : KXXXXXXXXX SysteLri PASSED The inspection «hich I have conducted has not found any information which indicates that the system fails to adequately protect public health or Lhe environment as defined in 310 CMR 15 . 303 , Any failure criteria not evaluated are as stated in the FAILURE CRITERIA sectiolj of this form . System FAILE )* The inspection which I have conducted has found that the system fails to Protect the public health and the environment in accordance with Title 5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . Inspector Signature Date 10/29/96 One copy of this ert.ification must be provided to t.hP nwurrn . f►_ ntrvr. n TO>WN OF BAIRUNSTALLE LOCATION 7 (�vx�l(� SEWAGE # VILLAGE,Y/e 5 ' ASSESSOR'S MAP & LOT iL`I INSTALLER'S NAME&PHONE NO. S, b SEPTIC TANK CAPACITY ,l�o LEACHING FACILITY: (type (size) NO.OF BEDROOMS p� BUILDER OR OWNER PERMIT DATE: Gb- �Jl`��� COMPLIANCE DATE: -7—A4 Separation Distance Between the: 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 fe of leachi g fow Feet Furnished J" r • if�����y�o -15-171 Lomb Amo r*04Q...) y LOCATION SEWAGE PERMIT NO. VILLAGE INSTALLER'S NAME ADDRESS �. .c• � e� M S U I L D E R OR OWNER DATE PERMIT ISSUED .. t DATE COMPLIANCE ISSUED � � LOT o � CIS j - -C_,O oo6' No....�s.M_ � FEs......s............ THE COMMONWEALTH OF MASSACHUSETTS BOARD- OF HEALTH fOV�lll,(......:...........OF..... P+ (�T.r' SLR....-........................ Appliration for Diipnial Workii Tonotrudinn Vlermit Application is hereby made for a Permit to Construct X).. or Repair ( ) an Individual Sewage Disposal System at: t)D 4Tae -�-1 I L.L. Location.Address - or.. Lot No.___ ---- '?4-„ ' 1nGSt-------------•---•---------- -•---........-•-•-----•-=---.... ..... .... ..:..................__ .._: r Addr s ................. �e� r.....� �T&---------------------------=- s - � �.._.......-::--......... . Installer Address Type of Building- Size Lot.(4*'DC575......Sq. feet Dwelling—No. of Bedrooms............. ........................Expansion Attic ( ) Garbage Grinder Other—T e of Building No. of pers6fis............................ Showers . — Cafeteria . at Other fixtures -- d bctl vuon� :.... WW Design Flow...........1..10.......................gallons per.per-sea per day. Total daily flow..........aZ.Q...................gallons. Gd Septic Tank—Liquid capacity.IOD_Ogallons , Length.$!:t�C-o.._ WidthA',"-.I&Diameter•—__ Depth.5!::A.'. Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No...__..._ . .....Total leaching area.W. �..'s ft. 3 pag �P+�_.. Diameter below anlet.._.�p.... g . . q. Z Other Distribution box x<. Dosing tank ( ) Percolation.Test Results Performed by.... l,?k4..CA.A..�t+l�al EIZtAYo Date......G/��,SE...... ,aa Test Pit No. L.4Z....minutes per inch Depth of Test Depth to'ground.waterqLAA:�4NE...... fit Test Pit No. 2................minutes per inch Depth of-Test Pit..................... Depth'to ground water........................ �+ --•-•--...--•................................................... ..............•-•-•--•----•----•-•--..^--------....._...............--•---..._........ ... Jf 0 Description of Soil___...G�?��:..L�o �--/..QQ122.� �la>!�....�3(a...4,�11QSDt.�..:y.. !__.....4$ .F3APj, �.5...Q1:.___._. v SaL�'. `.5+4 �_4� -_/- i!.. 1..�4,sar.�4,c.t© ►v� ................................................................ 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 provisions of LI':L. 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation u a Ce tificate of Compliance has been iss ed by the b r f health. Q %moo Signed..... C. ,[ .. Date ........- '. rr Application Approved IIY b-------------------- -----••-----•---.:....------•-------- ...... Date Application Disapproved for the following reasons:...-..........................................--......-•------••-------....-...............................--- ..--•...........................•---•---•---...........................-......--•---••-......_...._...........•--• r ---•-•--._......._............................................................ Date _ PermitNo......................................................... Issued....:.......... 00, Date .( a ti} CC) ­t THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...01111V,.t..................OF.... !! A 1 hfi.C_. '_................------------ Apli iration--for Diinpoaal Works Ton.6trurtion f rrmit Application is hereby made for a Permit to Construct O or Repair ( ) an Individual Sewage Disposal System h!`_�_.._. (---pT ..�.. Location Address 1 or Lot No. ......:..:..:-...... ..�.... ........................ ---•-••--•-•___........__------..................... --- ... --------------------------- ner Address ` �. ,�.............. Installer Address Type of Building Size ........Sq. feet U Dwelling—No. of Bedrooms............................................Expansion,Attic ( ) Garbage Grinder ( ) Other—Type of Building .........;.................. No. of persons....:._L:.................. Showers ( ) — Cafeteria ( ) Pr Other fixtures - -d y Design Flow...........1J�___....:._ _.._gallons per.person=per day. Total daily flow_.._.... ��— ..... ...........gallons. Septic Tank—Liquid capacity 1D n( gallons Length 3,�!::!�.. Width ;.`_S®'Diameter---.........!__ Depth.5. .'-A" W Disposal Trench—No. .................._. Width.................... Total Length M Total leaching area....................sq. ft. Seepage Pit No.... 1e:... Diameter........ ....... Depth below inlet ..!r:_l...::...°'Total leaehmg areajM:1.._.sq. ft. t Z Other Distribution box;(` ) Dosing tank ( ) Percolation Test Results Performed Date.....1_��4 ...... ,Wa Test Pit No. 1_ ....__minutes per inch Depth of Test Pit.... Depth to ground water.,U.e-'-*1.�:__.... (x Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ t 0 Description of Soil...... �' �`_ f1.I..j..G ter? i f `��" A�-�l-____�'',4Ci in --•- ..'_-./ 74!!-C..... ._w A�(_rr 5 ''`{y — -=•---•••----•-•... V 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 provisions of TITI 5 of the State Sanitary Code— The undersigned further agrees not to place.the system in operation u a Ce tificate of Compliance has been issued by the bo r� f health. _.__ ................... .. -� Signed-•-....__ !.. . �1 ................................ _fir �,.. `J. 11Ae Application Approved BY ---------- Application ::..::. !!.�[.~ �g- Date Application Disapproved for the following reasons:................................................................................................v............... .....................................•-..._--•••......_.__._._................___--•---•..._._.__._.,:... ______.._--••----__________..._......_..._ ____.._...._•• • .............. Date PermitNo......................................................... Issued.= .................................................. Date .._..e.r . .w, W� «. ._ ....... ...... .. .. ._.�.}.� _.. .... ._....._..........,.r...._.... n._ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ./,. ............OF.......... nil/ �' .` ...................... Trrtif iratr of Tomplittnre THIS IS TO CERTIFY, That the Indiv' ual Sewage isposal System constructed (/,/<or Repaired ( ) by.................".'...•••----....•--...........----•-------•----------•_ � 1���� '. ✓1teS� ...--•-------................._........................................ jJ lnsta er (has been installed in,.accordance with: the provisions of TIT LE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No....... .__"r�tl' I....... dated_...._...0A---�:_._� ............ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE I ,�•r• z4 :.:.......... or LJY -- •-- . � d ..... ...... .... rV, =� _ _ _�-. .......... ......... .... > ..r Inspect `' aLw a}a +.Y¢iN " THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 49 7/1 IF Disposal Work Tnnotrurtion if,rrmit . .. f Permission is ereby granted................... ,d ....... ....... ..................................................... to Construct (V)o epair ) anjudividual Selvage Pisposal Sys ._ ............'..:.Yr_-_/moo y�n� / .. .... .. . . ,,.. Street as shown on the application for Disposal Works Construction Permit o.�s -��?Aja d___.._I_t_-':`�.......sa'. ..... ►o . ................................ Board of Health DATE.............--..: ........................... •--_--...•--•y :. _ k I SECTION — SEWAGE a. -SEPTIC TANK - Z - "D"-BOX Z - -LEACH TOP OF FDN t; —'2 OF I/STO:b.. .. WASHED STONE t l� IN- OUT- IN' OUT- IN. I?,-'I, S T EPANKTIC �Z� 2j ELEV. ELEV. ELEV. ELEV. ELEV. ELEV. --- OFV4"-11ho WASHED STONE - f2/: ov �nry� � �� lnca'e_ I e `..F'�� ► '� ,i � ��� ., -� .. TEST HOLE LOG TEST BY WITNESS ti4 Si. c> ` ��• TEST DATE DESIGN BEDROOM HOUSE '^ U \spa \ T.H.- 1 T.H. # 2 t 1 6 OI; ye ELEV. �'�3. ELEV. -'t 6 I �-• `O ( �� \ 2 DISPOSER DISPOSER / : s� 132,5 PERC RATE MIN/W. o \ s FLOW RATE Z2n(GAL./DAY) , SEPTIC TANK Z`z� {� �_ 331=> '"' REQ'DSEPTIC TANK SIZE t coo cam _ zi qV-7 LEACH FACILITY SIDE WALI + I� 2.�) s 327:'l� .G/D o T 1 Z � x� BOTTOM �, O) _ _112) . 1 G/D G 5F 144 m l ,o I TO A 'L(p7j �-G'I D, FT cy USE: � LEACHING WATER ENCOUNTERED NOTES: (UNLESS OTHERWISE NOTED) R�G»SG'r'1Dhl. OF 1 t i I + p cw c k QUADRANGLE MAP pro^' I r 1.DATUM(MSL)—TAKEN R I`t l — r ' 2.MUNICIPAL WATER" -AVAILABLE { 3.POPE PITCH:W"PER FOOT 4.DESIGN LOADING FOR ALL PRE-CAST UNITS:AASHO- IA —1 f7 -44 �`>♦{ OF S.MIN.GROUND COVER OVER ALL SEWAGE FACILITIES:(1)FT.6 PIPE JOINTS SHALL BE MADE WATERTIGHT �cp' 7.CONSTRUCTION DETAILS TO BE.ACCORDANCE WITH COMM.OF MASS. ARNE H. GG STATE ENVIRONMENTAL CODE TITLES OJALA 1. ,;; �71 1 G PLAN CIVIL AlLOCUS: LoT r3 QiytgyGOMf3 CiR G�.(C �lo-e- eta✓ uD ram �azoe.�`f a_.vG.��d.+=.�►v �. A LL v rasv�-ro rbc,r M a.TEtrI . �o-� *�ov E� s�,�t n _ A - _ of T�1�RiJ5'�° ZSIrE M _ ;%�p,� Mqs� --htcsr, F�LAC�D W1TLt Gt-rcl�.t`I f��.T�SE^ "To RE NGINEER`. �O2 l(71 Aizounln I�aLIb-1Co-/�f��A•. ARNE G� REF: Ly 13 �UME2ttllt.:n �.G��387�1 ®�IAI C��� ���'A/l��I'9OI�' H. LG-F.��L_ ScL_taa..�s EPREPARED F • r t•-• FOR: CIVIL UR EYO ENGINEERS -R - H R �. 1D/,3� BOARD OF HEALTH g� �h�. LsAN� �n b 1 .�•� ND SURVEYORS ,t (EXISTING)............. ,A{3�,E �+ry; SCALE r1O CONTOURS APPROVED DATE MA D E '(PROPOSED) I