HomeMy WebLinkAbout0164 SADDLER LANE - Health 164 Saddler Lane
West Barnstable
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Commonwealth of Massachusetts
' Executive Office of Enviroiunental Affairs
Dept. of Environmental Protection
One winter Street Boston Ma. 02108 .lolui Grad
' D.E.P. Title V Septic Inspector
P.O. Box 2119
Teaticket,MA 02536
WILLIAM F.WELD (508) 5 9
Governor
ARGEO PAUL CELLUCCI A fO
Lt.Governor
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION U�
A0 8 1997
Property Address: 164 Saddler Lane W.Barnstable Lot 58 Address of Owner: HfA�( DAB(f
Date of Inspection:8112197 (If different)
Name of Inspector:John Grad Siegel ,`
I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000)
Company Name,Address and Telephone Number: �, y
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:
X Passes This inspection is based on criteria defined in Title V
— Conditionally Passes code 310 CMR 15.303.My findings are of how the system is
performing at the time of the inspection.My inspection does
Needs Fu er Evaluation By the Local Approving Authority not imply any warranty or quarantee of the lonqevity of the
Fails septic system and any of its components useful life.
Inspector's Signature: Date: 8/13/97
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspections. 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:
X I have not found any information which indicates that the system violates any of the failure criteria
defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below.
COMMENTS:
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 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, 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 infiltration or exfiltration,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.
(revised 04/27/97)
One Winter Street • Boston,Massachusetts 02108 . FAX(617)556-1049 9 Telephone(617)292-5500
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 164 Saddler Lane W.Barnstable Lot 58
Owner: Siegel
Date of Inspection:8/12/97
— Sewaae backup or.breakout.or hiah.static water level observed.in.the distri.bution box is due to a broken.
or obstructed pipe(s)or due to broken, settled or uneven distribution box.The system will pass inspection if
(with approval of the Board of Health). Describe observations:
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled 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 IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 feet to a
surface of water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply 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 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 presense of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method used to determine distance (approximation not valid)
3)Other
D] SYSTEM FAILS:
You must Indicate either"Yes"or"No"as to each of the following:
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.
Yes No
Backup of sewage in facility or system component due to an overloaded or clogged SAS or
cesspool.
Cischarge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged
cesspool.
SAS is in hydraulic failure.
(revised 04/27/97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 164 Saddler Lane W.Barnstable Lot 58
Owner: Siegel
Date of Inspection:8112/97
D] SYSTEM FAILS(continued)
Yes No
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Numbers 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"as to each of the following:
The following criteria apply to large systems in addition to the criteria:
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
pubic 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 is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area (IWPA)or a mapped Zone II of a
public water supply well)
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 04/27197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECLIST
Property Address: 164 Saddler Lane W.Barnstable Lot 58
Owner: Siegel
Date of Inspection:8/12/97
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
— Pumping information was requested of the owner,occupant, and Board of Health.
x None of the system components have been pumped for at least two weeks and the 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.
x — As built plans have been obtained and examined. Note if they are not available with N/A.
X — The facility or dwelling was inspected for signs of sewage back-up.
X — The system does not receive non-sanitary or industrial waste flow.
_x_ — The site was inspected for signs of breakout.
x All system components,excluding the Soil Absorption System,have been located on the site.
x 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.
X _ The size and location of the Soil Absorption System on the site has been determined based on
The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of
Sub-Surface Disposal Systens.
X Existing information. Ex. Plan at B.O.H.
x Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is
unacceptable)115.302(3)(b)J
(revised 04/27/97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 164 Saddler Lane W.Barnstable Lot 58
Owner: Siegel
Date of Inspection:9/12/97
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 330 g•p•d.lbedroom for S.A.S.
Number of bedrooms: 3
Number of current residents: 2
Garbage grinder(yes or no): No
Laundry connected to system(yes or no): Yes
Seasonal use(yes or no): No
Water meter readings, if available:(last two(2)year usage(gpd):
n/a
Sump Pump(yes or no): No
Last date of occupancy: n/a
COMMERCIAL/INDUSTRIAL:
Type of establishment: n/a
Design flow:n gallons/day
Grease trap present:(yes or no) No
Industrial Waste Holding Tank present: (yes or no) No
Non-sanitary waste discharged to the Title 5 system: (yes or no) No
Water meter readings,if available: n/a
Last date of occupancy: n/a
OTHER: (Describe) n/a
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System was last pumped 2 years ago.
System pumped as part of inspection: (yes or no)No
If yes,volume pumped: 0 gallons
Reason for pumping: n/a
TYPE OF SYSTEM
X Septic tank/distribution box/soil absorptions system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) ( if yes, attach previous inspection records,if any)
I/A Technology etc. Copy of up to date contract?
Other:
APPROXIMATE AGE of all components,date installed(if known)and source information:
1986
Sewage odors detected when arriving at the site: (yes or no) No
(revised 04/27/97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 164 Saddler Lane W.Barnstable Lot 58
Owner: Siegel
Date of Inspection:8/12/97
SEPTIC TANK: X
(locate on site plan)
Depth below grade: 1'
Material of construction:X concreate metal_FRP_Polyethylene_other(explain)
If tank is metal, list age 11 . Is age confirmed by Certificate of Compliance Yes (Yes/No)
Dimensions: L 8'6'H 5'7'W 4'10'
Sludge depth:1"
Distance from top of sludge to bottom of outlet tee or baffle: 26"
Scum thickness:2"
Distance from top of scum to top of outlet tee or baffle:6"
Distance form bottom of scum to bottom of outlet tee or baffle: 16"
How dimensions were determined: Measured
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.)
Septic tank and all components are structurally sound.Recommend pumping septic system every two years for maintenance.
GREASE TRAP:
(locate on site plan)
Depth below grade: n/a
Material of construction: concrete metal FRP Polyethylene_other(explain)
Dimensions: n/a
Scum thickness:n/a
Distance from top of scum to top of outlet tee or baffle:n/a
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
Date of last pumpingrg
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.)
n/a
BUILDING SEWER:
(Locate on site plan)
Depth below grade: 16'
Material of construction:_cast iron X 40 PVC_other(explain)
Distance from private water supply well or suction line:town
Diameter: 4•
In/amments:(conditions of joints,venting, evidence of leakage,etc.)
(revised 04127/97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 164 Saddler Lane W.Barnstable Lot 58
Owner: Siegel
Date of Inspection:8/12/97
TIGHT OR HOLDING TANK:
(1!ocate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_FRP_Polyethylene_other(explain)
Dimensions: n/a
Capacity: n/a gallons
Design flow: We gallons/day
Alarm level:_n/a Alarm in working order?_Yes_No
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
We
DISTRIBUTION BOX: X
(locate on site plan)
Depth of liquid level above outlet invert: Liquid levelwith bottom ofpipe.
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box etc.)
abox is structurally sound.
PUMP CHAMBER:
(locate on site plan)
Pumps in working order.(yes or no)No
Alarms in working order(yes or no)_yes
Comments:
(note condition of pump chamber,condition of pumps and appurtenances, etc.)
n/a
(revised 04127/97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM.
PART C
SYSTEM INFORMATION (continued)
Property Address: 164 Saddler Lane W.Barnstable Lot 58
Owner: Siegel
Date of Inspection:8/12/97
SOIL ABSORPTION SYSTEM(SAS):X
(locate on site plan,if possible; excavation not required,but may be approximated by non-intrusive methods)
If not determined to be present, explain:
n1a
Type:
leaching pits,number: 1,000 gallon leach pit
leaching chambers,number:n/a
leaching galleries,number: n/a
leaching trenches,number, length: n/a
leaching fields, number, dimensions:n/a
overflow cesspool, number:n/a
Alternate system: n/a Name of Technology:_n/a
Comments:(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
The overflow is structurally sound and functioning properly.lt was 1/2 full at the time of the inspection.
CESSPOOLS:
(locate on site plan)
Number and configuration: n/a
Depth-top of liquid to inlet invert: n/a
Depth of solids layer: n/a
Depth of scum layer: n/a
Dimensions of cesspool: n/a
Materials of construction: n/a
Indication of groundwater: n/a
inflow(cesspool must be pumped as part of inspection)
n/a
Comments:(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
n!a
PRIVY:
(locate on site plan)
Materials of construction: n1a Dimensions: n/a
Depth of solids: n!a
Comments:(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
n/a
(revised 04/27/97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
164 Saddler Lane W.Barnstable Lot 58
Siegel
8/12/97
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references, landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
L
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Q
AC
8A
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(revised 04/27/97) flag• 9 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
164 Saddler Lane W.Bamstable Lot 58
Siegel
8112/97
Depth of groundwater 12,
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from design plans on record.
Observation of Site(Abutting property, observation hole, basement sump etc.)
Determine it from local conditions
Check with local Board of Health
Check FEMA Maps
Check pumping records
Check local excavators, installers
x Use USGS Data
Describe in your own words how you established the High Groundwater Elevation.(MUST be completed)
USGS Maps and Charts
(revised 0427/97) Pays 10 of 10
ION LOCAT S„EWACE PERMIT NO.
VILLAGE
INSTA LLER'S NAME i ADDRESS
B U I L D E R OR OWNER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED ly
G-2`
f =ti 1S 1 - Oc) 4- - oc> f, ems'
No...g�:.19 Fims.. ....s .
THE COMMONWEALTH OF MASSACHUSETTS
r g ( BOARD OF HEALTH
Q. .................0 F...... .�-5✓-_-
Apphratiou for Di4pngal Warkii Tiantitrurfiurt runfit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at:
Locatio-- -,Ai d e s h t No.
-------------- - - .. ....------........... .....---• - -- ly r ------•••- -•••-•................--------
.� Owner/� Address.
1 (... ��Y. . ............ ............... ...`-% a .1.�1.�.....--•-------•---.....---
�nstaller Address f1 —7
Type of Building Size Lot.-f�j ---_------Sq. feet
U Dwelling—No. of Bedrooms................ ..........................Expansion Attic ( ) Garbage Grinder
a'4 Other—Type of Building No. of persons............................ Showers
g ---------------•----•---...- P ( ) — Cafeteria ( )
Otherfixt es ................•--••--------••- ----------•-----------------------•------------------
� G�Yc)e7�1 ,`}
W Design Flow............�.._LU_...........v.rt gallons per ?r day. Total da}lyCf�ow...........9,f_ C .................g�llon�
tx Septic Tank—Liquid capacity_.®_S!..gallons Length. ._ �._. Width. .4.... Diameter................ Depth�_t l.0... -
W
x Disposal Trench—No. .................... Width...l.__............. Total Length...............?--- Total leaching area....................sq. ft.
Seepage Pit No._.....I............ Diameter..... .......... Depth below inlet.......&........ Total leaching area..().l-..sq. ft.
z Other Distribution box Dosin tank /
'-' Percolation Test Results Performed by._ ... Date.... ._..�_ ._. 5..
Test Pit No. I__�2..minutes per inch Depth of Test Pit---L.W.0...... Depth to ground ater....
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
wtt { tt +� .-,--------------- 1... � f
O Description of Soil .......��. - .�? J.�.L-....1- - �'� .. . . l. 1 �4�
x .............................
- i�----.. iL,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 provisions of IITHE 5 of the State Sanitary C e—The u ersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee i bo f health. J
Signed...... ....... --- --- ---- ------•--•-•------•-•---•----- -----........
Date
ApplicationApproved By.................. . . ........... ........................• •••-• --......... .•-- i J- .......
Date
Application Disapproved for the f of ing reasons----------------•----..........---•--------------------------------------------------•----•------...._..----•---
----.......-•-------•....................•--•---•-•-•-------------.........---------------•-•-------•-------..................-------------------•--•----------•-•--•-------•--•-------••-•------•-•----
Date
PermitNo......................................................... Issued_.......................................................
Date
----------------
No......................... Fmc.........................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
UJQ................OF....... ........................
Appliration for Dispaiial Works Tunatrurtijan Prrutit
Application is hereby made for a Permit to Construct ( 0 r Repair an Individual Sewage Disposal
System at: )4_
C .................. 401�s �.._.. : #�......................
-------------- C�Aocation-A No.
.............
....... . . .... ................... . ............................................. ..............................................
0 Address
................ ........
Installer Address
Type of Building Size Lot...ZQ,-.6w]
U .....Sq. feet
Dwelling—No. of Bedrooms................. ........................Expansion Attic Garbage Grinder
Other—Type of Building ............................ No. of persons............................ Showers Cafeteria
<04 Other fixtljj�es ............................. ........................
......�A'VUVv--------------------------------------
Design Flow.............LUU.............. gallons per P@S"R 7 da v flow...........
Septic Tank—Liquid capacity. gallons f Diameter________________ Depth4-
(y. Total da� i
Length... .....(a-(.. Width---9_-�4 ...
Disposal Trench—No..................... Width.....l............... Total Length............_...I--- Total leaching area....................sq. ft.
Seepage Pit No........)......._.... Diameter......t)......... Depth below inlet._......._..... Total leaching area.2_0.1_-Jsq. ft.
Other Distribution box Dosing tank
Percolation Test Results Performed by_ T_J.A 3�>
......... Date
Test Pit No. 1... -minutes per inch Depth of Test Pit...1.(412.1....
Depth to ground Vat ..... UOti...C
4, Test Pit No. 1............."..minutes per inch Depth of Test Pit.........._.-....... Depth to ground water........................
P4 ... ............. ........ .....
0 Description of Soil--.-&........ CC
::12. ... ....... ........................................
U .................................................................................................................WL ;AA' Dw ,
W .....(*.....T. - ........-.4.1-T-----------------------------
�r I .......................................................................................................................................................................................................
U Nature of Repairs or Alterations—Answer when applicable................................................................................................
........................................................................................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
OW-ration until a Certificate of Compliance has been issued by the board of health.
Signed..
%S
Application Approved By........... ........................... .........IQ D
Q...................
Date
Application Disapproved for the foil ng reasons:.........................................................................................................
.........................................................................................................................................................................................................
Date
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF........................................
(Intifiratr jaf Toutphaurr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired
by--------------------------------------------------------------------------------------------------- .I _"----------------------------------------------------------
------------------------------------
Installer
at
has been instaflf!d in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No......................................... dated_.....__._____
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTFUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE........................ .......................................... Inspector................ -- ------ .............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...........................................OF....................................
No:-.......................?p �5 C>
FEE........................
Dispaiial Works Tonotrurtion "prrutit
Permissionis hereby granted........................................................................................................................................
to Construct or Repair an Individual Sewage Disposal System
11at No
Street j?
as shown on the application for Disposal Works Construction Permit No.__.....5........--j
...."Dated
-- --------- -----**
.......................................... -_------- - -
of Health
DATE................11 71.'4?-5....................................
FORA 1255 A. M. SULKIN, INC_ BOSTON
LOCATION SEWAGE PERMIT NO.
VILLAGE N5€, I96
I N S T A LLER'S NAME & ADDRESS
�D
i �
8 U I L D E R OR OWNER
~ Le� \
DATE PERMIT ISSUED om fffi
DAT E COMPLIANCE ISSUED
s a�`�.\�� `�,,
�I / ��,
1 ►�
�7 �
No4 ...._ FEs.. ._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Cow. l..........oF.. zt sT . ............................. `
Appliration for Mgpaaal Warkii Cnnnitrudivan. rrrmi#
Application is hereby made for a Permit to Construct (Y_�_or Repair ( ) an Individual Sewage Disposal
System at
................___.:Jra'C..5_C1 • _.�,.�__F...Pre..��.(. ....I��... �1.��^(�..,_—J�L • _ ---....... .
Locat• Address n-Add r _ or Lot No.
.........._L r .... .moo-c. - -- --:...--- ---- =-- - ....._-----•--- -
ow Address
Installer Address
Type of Building ? Size Lot
....
�.S}.l�? ....Sq. feet
Dwelling ' No. of Bedrooms________________ ................... Attic ( )' Garbage Grinder ( )
Other—Type of, Building No.. of persons............................ Showers"( Cafeteria
Other fixtures ...:.............................. ..��
W Design Flow............LID................•--_--gallons per peFsen �t day. Total dailyt�iow...-._...........-��__..._....__:,g�llor}�.
WSeptic-Tank—Liquid capacity._10vC�_gallons Length._- ..�p-__. Width-�J,__LG.��.._._ Diameter........:....... Depth._�__`-JL-Q-...•
x Disposal'Trench—No......::............ Width.................... Total Length...................... Total leaching area.....................sq. ft.
3 Seepage Pit No...........t--------- Diameter.......LZ ...... Depth below inlet_._..............Total-leaching area: 3.-sq. ft.
Z 'Other Distribution box V y Dosing tank ( ) 00,
'-' Percolation Test Results Performed by.1-57LD Z.E12..0 .... 1i .:..._._.... Date__..:._'' ..ZCa
Test Pit No. 1....L-2_minutes per inch Depth of Test Pit.-....I .`�. Depth to ground wa er.._
G4 Test Pit No. 2... _2..minutes per inch Depth of Test Pit......L.�.�-__(p.... Depth to ground water....NW..NIE.
a ._...:_..�........:.......E_.._."_.................._...ti I................... ...................................................................
.................-- --....... ....
O Description of Soil..1.. ....4rQ.A ..i.._ew-vf�....12 .....1A...Q F1 .: _ll t_S_.WJD Z-1,F�
-__._-••--------•-..•--. :... .!! y.. .............................#. = 'l= S.�.. (� ........................................
x :...� I4.-.-_1e� �`� �..........:..�`!� 0 .........................-•...............-----••-•
U Nature of Repairs or Alterations—Answer when applicable....................................................................-...........................
Agreement
The undersigned agrees to install the aforedescribed Individual Sewage Disposal,System in accordance with
the provisions of LITLZ 5 of the State Sanitary Code— The under ' ed further agrees not to place the system in-
operation until a Certificate of Compliance has been ' e t b d lth.
ed... --• t _.••----•............ . ....... .....�. .... ...
at
Application Approved B — '
Date
Application Disapproved for the following reasons:.............:........•-••----.--...-._.:-----------•--•------...-------•--•-•--•-----______.....................
........................ .••---.._.._......__.........-- ----............-•--••--•---.....................................................................----- - ...........---
Date
PermitNo....- .............. Issued...:............. ..........•-------...... .....
Date
FEs NO *7 y. ` 1CW
r . .....�...:?.........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
APpliration for Ropoiial Workii Tonotrudion ramit
Application is hereby made for a Permit to Construct ( Z or Repair ( ) an Individual Sewage Disposal
System at:
................__....��n::�..� .. : :... h, _i 1 :1?. ! `1: :.. - u ts:t 2. H!L L . ................
Location•Address or Lot No.
...........� _.�? r--_ '=_ca t Mtn................................. ....................................................... --
Own Address -
M Installer �` Address
Q7i Type of Building ^�� ' `"' • �6 ; Size Lot....�..�•-'.iJ.9.) ....Sq. feet
6; �,
.a Other Type oof Ba>l� ooms .� :.. :; No.`+ofpersons nsion Attic ( )Showers Garbage Grinder ( j
a Oer fixtures .g............ ................... f_...... ..._.......... ....-..._ ..... ( )... •Cafeteria ._......
a
d P t b�drn°v� ;-F-
Design Flow..................0.................._...gallons per person p!r day. Total daily ..............
Septic Tank—Liquid capacity..000.gallons Length...r'G�-U!.... Width�.,-A.... Diameter................ Depth. :..�.U....
x Disposal Trench—No..................... Width.................... Total Length.::.............. Total leaching area.....................sq. ft.
3 p q• ft.
Other istribution box Dosing tank
Seepage Pit ,No...._......I.--....... Diameter.......�_�...... De th below Inlet...:4_.........Total leachingarea.Zf�
Percolation Test Results Performed by. :1.. J"C .(- :...0 �C?'1. ............ Date._...-_�� a.�� i '�5�....
a - � .
,.a Test Pit No. 1....!� .minutes per inch Depth of Test Pit...... _ :..:__ Depth to ground water...!�..1�1�. ....
fZg Test Pit No. 2.. 2_-.:minutes per inch Depth of Test Pit......�.�.-( ��..Depth to ground water....i�(��h�
a ..........
................I..•.....................--•................---•-•.................................................................................
Description of Soil ..._. .4.'..! !.G..r�. ...12 .t-••- D:. if �= =��)•Z. .�aAti(tJ.�a t �.IF t Du!�� �t� ;
.................................... --• ..t ........................ ,+-------------------------------------------------------------------............................
U Nature of Repairs or Alterations—Answer when applicable....................................................................................
..,...,.....
... -----••-•� -•...............
Agreement: .......
....._.
The, undersigned agrees to installthe aforedescribed Individual kwage Disposal System in accordance with
the provisions of TITLE, S�ofFthe-State Sanitary Code— The under ed further agrees not to place the system in
operation until a Certificate of Compliance has been • e t e b d lth.
_.___.__signed....... .....: .. .. .................................. ..... --
i att!
Application Approved B s'` :...............................•--•.....................
Date
Application Disapproved for the following reasons:..........:...•--••-•-•--.........--•-•-••-•--•-•-•••--•••---•••-------•---•--................................I..
.............................................•••.....--••-•-...--••-•-•---.....---...---........-••-..............-----------•-•••-•-••...:............................................................
Date
PermitNo........ �� L ............ Issued.......................................................
Date
i
THE COMMONWEALTH OF MASSACHUSETTS
BOAR OF HEALTH
..................... ..........OF. r,,11)A._Vj)k/, 1.1.1....lk lr:., ....................
Trrtif ratr of Toutpliatta
TH44P
S,TO VRTI Y t the I " -idual Sewage Disposal System constructed (or Repaired { )
by - �� `�e� _f� .....--••--•-------••........................••-------------....---....-.-................-•----------..........Inat_....... �.-•-- .... .--- 2-- :•- ... .z-� .t •••.. . .....-•----...---•--------------••----......--•-----.......---.....
has been installed in accordance with. the provisions of T :^IP 5 of The, State Sanitary Code as described in the
application for Disposal Works Construction Permit No. �... .................... dated.....----�-.��1� `� ..................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. -�- -'
DATE........... ... ............. Inspector-----................... ...
........n•.a....�«,.>. a .,._,,.,�_..+<„Y....�.. .x..w..............a.......w��rn .......................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD° F HEAL.T
f
,/ -
1
� '; •� l ..........................................oF. l., �..........1.........
No
�io�iao�tl ork� onotr�lc,�,'on � i#
Permission is her granted.......... -f `'^�-.�.a ...... �, ,r�'�:. iZ .....................................
to Construct ( r R ( an Individual .wag. is o System /
at No. e ... -_ �.._.._...... .. r ...../I .......................••••-- .....-----••
.1...w
Street �-•- •
as shown on the application for Disposal Works Construction Permit 110.... _f........... Dated.......t. . ....................
1 v Y Board of Health
DATE.. ..:.��(;?-'ITd-.. ---------------------------------------
SECTION - SEWAGE
-
A'
— r
I11
Y.
i
2 —SEPTIC TANK— %' _,.b..BOX - LEACH
2
TOP-0 FDN J
IrQl�Q(MSL)N ..2..OFt/eTOph"
'` r yyASHED STONEMQQi'A•. >
,
13b,o :
r
<
t
.: a '. .,.. .. .. .-. ...... .y..A ,... -, ...• .. �l
...,.OUT _ray nia:x tit,
IN• UT-
IN :
OO , SEPTIC -
t.
.; - <: .TANK4 -
1 �. . .
ELEV.
.a- 4
LE £LE j t r.. .-
•r, r.V.
.r
E LE a f.
ELEV. i>
j� :K
r � � F
k s
.. h �—�. s,
c: :13_ r>x
T
">
»,
PA
IdEO
. : - -.,. V. ,e• .� , : ,o. -,. rti. ems, �
LE BOGS 3 I vM o t rx :,� x_r ' i
TEST HO,.: R q
f s
2rat-b4t-t k� ---1. Co►'l ta,!'t �'. _ sI
• TEST BY
p, WITN ESs M_.. {�
TEST B�DROOM-HOUSE
:DESIGN
T.H. alt -i T.H. all 2
E V. ELEV. No d .
-
co
OISPOSER GI$POSER 4.. 's t
i PERC RATE G2 MINAN. (... rda,,> N
1 1' t;
K (GAW.DAY)
l let
SEPTIC TANK D I, _
T
o
REQ DSEP IC TANK SIZE
}
LEACH FACILITY da _
SIDE WAIL G ISO �y7tio:8' 'G/D. - "
{�
(2.5
r �� I50
BOTTOM 8 Z _ t�O} 5U,ZA 611).
<, a
TOTAL'.. Zod,�6Q, a 7-0
t
USE: �� .: LEACHING
sTEG
WATER ENCOUNTERED
WE
NOTES. .(UNLESS OTHERWISE ;NOTED)
1.DATUM(MSL,)~TAKENFROM ��'41Jh�.11c� QUADRANGLE MAP �I I I , �•Y I
2.MUNICIPAL WATER 12 AVAILABLE_ t ���
. {
3.PIPE PITCHt 14"PER FOOT I / �wltNf
4.DESIGN LOADING FOR ALL PRECAST UNITS AASHO /'t �y -44 �"" �i �� i
S.MIN.GROUND COVER OVER ALLSEWAGE FACILITIES:(1)FT:
6.PIPE JOINTS SHALL BE MADE WATERTIGHT .'� ARNEN
. G �'
7.CONSTRUCTION DETAILS TO BE ACCORDANCE WITH.COMM.OF MASS. OJALA /
STATE ENVIRONMENTAL CODE TITLES .-Cl `H'OF k SITE` PLAN
$ Ty b'.�a_A�J F 4L 7���^�a wcJtLIC Cw.ta_rC a.�b �taca��� • " d LOCUS:LoT S8 SIEDpL cmu ''L-A JE
►..toe- ql a= tJ D �a� .'�za�L `CAIRN L„tG- fT`d.�a+. ►Gs , . /� G
— M• NEST 1�- W�NSTt�I�.� `;``t✓�
RE(3: 1 NGINEER , _--.. .. OJAL A
J REF.
w I-t4 '•� wo&r-hft---to M e b Y �1d.L�b r-or----Id ! ifOwo cape ee#1iaeerinl ��f C PREPARED FOR
> OtJt�►� L �-�4-irk ,dam , _
CIVIL,ENGINEERS
LANOSURVEYORS ----= --- �{
BOARD OF HEALTH REG.LAND SURVEYOR
f)/-\ rA►3t-�
CONTOURS (EXISTING)
-0-0-0-0- APPROVED DATE MA + ' Y .YA SCALE
, k e
SECTION - SEWAGE
• � ,. .. 3� � �I T � bEVEI,oPi�taT,
SEPTIC TANK- 9 - D BOX- . -LEACH 73 fo1KF_�4i T10140P1
TOP OF FDN r e F`9W 30 T�
�t. glpE � �._ �.
�:.�:'...(MSL)• _..Z..OF a/eTQ Mi" — � _ �'
WASHED STONE ;' IZ � �.1 Ja
F '
14)
r
rn c n (' cr"bvGr
IN• OUT• IN SEPTIC
TF
-
1'--� TANK
ELEV. / I '
ELEV. ELEV. ELEV
ELEV: ELEV.
1
.__. ``
WASHED STONE
,
2 qq w l2 :-. r TEST .HOLE LOG - —
TE - -
•
:
c,ot�! ,o. r I\ A
TEST BYWITNESS ''.TEST DATE 3 . �aBEDROOM HOUSE�E�71C1N T.H : tELEV. :I ,. ELEV.t2a�J=, ' -:,.{ ., . ..>. - . ' , ,��,< 2,,'.. DISPOSER_ :..DISPOSERII 11,5 1-�� PER >RATE M.I hN. _ V \FLOW RATE Z20 (GAL,/DAY) Z '' '
1'1�D FI SEPTIC`TANK,? 'TIC
r (I,5)�'
s D1E
�J I L R EO D SEP TANK'S
t
4•' a�' a
o ,r 1.
v N
_N•
3-
� . V SIDE:WALLBoTl
P
3 r} a
M1
i;
eQ� r
j,
a 1 4 a ,
,
A
l
USE
e
O
, .. WATER ENCOUNTE ED ,-
f
4 4/
1• L•"
NOTED).
., UNLESS OTHERWISE
-
,
: •
a.. � w
d
—TAKED�FR M DU
1.DATUM f11A5U
9s
e 5.. �„ VAt BLE
- .MU iC P WATER •"'
. t N ,, .• r:•
t•'4r PER FO T.
3.PIPE PITCH O •'
AASHO t'T' .44. :,'
4.DESIGN.LOADING FOR ALL PRECAST UNITS:OVER ALL SEWAGE FACILITIESs 11.FT.S.MIN.GRgUND COVER O (
. MADE WATERTIGHT - - - - .. :'::.- ,,:. ,,�,�' • . .�. ,: ,. :`r�+, ,{
8.PIPE JOINTS,SHALL BE -
ORDANCE WITH COMM.OF MASS.
.., OJ CA .a r.t t
74CONST CONS
TRUCTION ET 1 TO BE ACC ,�'. ' r
TEENVIRONMENTALCODE.TITLE
nA ��� PLAN
� ... p�,..e.•_.1 -LOCUS. -
r
a
-
-
T M
O. NE
E
t
}
J I�
-614
...t - - :.. ;. w ... ...... .. ...,. 3:.. ,:v.-._ - :,.,.... :,Y: ':l:tl �5,. i P..• `.
., �. . �l t
V l�!I a•t��' t :, _ .. • : .: >,_ ,� ._< . .t,.._,. , .. _ .. QQw >., EP',x E. F.,�
. 2...
.,- N+r,�IN ,,.�``
.,
.r ,u: .. i �.t ....-. ,..a . , ..,.. _ ,.�.. } t� .. ,. ♦. .,.. .rt >... ...e -l�# .. � +t,'e
.L .. ». H • -..ter. .. a _., .... ... ._, .... ... .71 . S ,��... .. s.a5t_... „j�
OR �;A
t e� ..
. ,. . ... . e:. i,.•.. . ..., ...... ,>:'t ., ,_. .., ..� ,,. ... , _.a, t. ls. v. r 1.4,. .mr. 4, try, �yys«,,. ...r>•
-.. .,a ..,. .. .. ♦.., ,. e.., .. n'. ... v . W. .- .. .- ,� �� -..R,. > ... _JS ,H. , ., .. ..,. ,, ,.: ,, r. EOARDOP HEAT .. k- •rr. '. ..( 1. 4 fr•" �%,,..
.: .. ..,, .� : _.� ..... .- .. -, .L. r. .♦ ...�' a ..« I��,...,try.. .. �{'�..N,- ..( ((QQ�� '"'3; 5,:.� �'�r�,. •r_ ., 4 : ', P f l" 2'- t'i" a2J
_ EXIST ) ... .; h ., :. .><..,. -...r .,,tl,a. a r.?!e. z .. �' ,� •,:d� '�" ui4:' s ,>r � , .i,' :^'t��'F �;-
L- ( .. -hF s 1 ..� r.;7•. .. ,.. ...w '4r..•._:___:} �A..... 7• - .�� ,, .5.,. 3}YA.w: P.zV�.,. k. .Y. '9 ry t tk' {{�'.`'+.
R VED e. „..« .:2r4 <y _.;. ( a t r, �}'s,ay5. i .r k. a. ,... ► .`xa. ...CONTOURS.
....,.,. .,<,. .; ..{ > (PROPOSED)'"q r•�fl!P...:d. _r-:r.:. ... .. �. ,..... t... t: �,: cy,�.,n x. , _ _ .�.;.. re z� �' - - .tr. sew,: d.u:, ,.a..,a
t