HomeMy WebLinkAbout0032 LADY SLIPPER LANE - Health 32 Lady Slipper Lane
M6rstons Mills P #
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THIS MORTGAGE I NSPECT j ON PLAN_ IS FOR .
BANK USE ONLY'
TOWN:_M;ARSTONS Mtji, S REGISTRY OWNER:-PETER L. & PATRICIA A. BRIGGS
DEED REF:-RKR 5016/ 94 BUYER:
DATE: 11/24/87 PLAN REF:_BK. 375/56 LOT 16 SCALE: 1 '= 60'
hereby certi y -t at the building
Shown on th-is plan is located on �XkA OF 'ate VANKEE SURVEY
the . ground as shown .and - it o�� cy�` CONSULTANTS
position does conform to the, PAULA. 70 RASPBERRY .LANE
zoning law setback requirement of 8 Mr=RffMEW N MARSTONS MILLS
No.32MG MASS 02648
and does not lie within the special OFESS���P�
flood hazard area. 'as shown on
u SUR�����,��
the h. . d. flood,. 19
ta p dated8
is p.:an . not made from an instrumen-t
Paul A. Mer thew, RPLS survey, not to be used for fences, etc �4_.... -
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COMMONWEALTH OF MASSACHUSETTS
Z f EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
s
DEPARTMENT OF ENVIRONMENTAL PROT CE TION
m� f ^/frt'�1^r
l�qM cNOy ��� � V L�U UJ
A 350 MAIN STREET
WEST YARMOUTH,MA TOWN OF BARNSTAgLE
508-775-2800 HEALTH DEPT.
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEMFORM
PART A
CERTIFICATION MAP 4-
MAP 044—PARC 170
Property Address: 32 LADY SLIPPER LANE PARCEL, ^V ( ® b 2
MARSTONS MILLS,MA 02648
Owner's Name: BRIGGS,PETER W
Owner's Address: P.O.BOX 1380
MARSTONS MILLS,MA 02648
Date of Inspection JANUARY 3,2005
Name of Inspector:("please print) JAMES D.SEARS
Company Name: A&B Canco
Mailing Address: 350 Main Street
West Yarmouth,MA 02673
Telephone Number: 508-775-2800
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:
✓ Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date:
The system inspector shall suPrrdtopy 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 tot he buyer,if applicable,and the approving authority.
Notes and Comments
T.,
r
****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.
Title 5 Inspection Form 6/15/2000 1
f
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 32 LADY SLIPPER LANE
MARSTONS MILLS,MA 02648
Owner: BRIGGS,PETER
Date of Inspection: JANUARY 3,2005
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:✓
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. Any 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,
ex-hibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing
tank is replaced with 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,settled 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 explain:
Title 5 Inspection Form 6/15/2000 2
Page 3 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 32 LADY SLIPPER LANE
MARSTONS MILLS,MA 02648
Owner: BRIGGS,PETER
Date of Inspection: JANUARY 3,2005
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(l)(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 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 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.
3. Other:
Title 5 Inspection Form 6/15/2000 3
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 32 LADY SLIPPER LANE
MARSTONS MILLS,MA 02648
Owner: BRIGGS,PETER
Date of Inspection: JANUARY 3,2005
D. System Failure Criteria applicable to all systems: N/A
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
�— Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded
or clogged SAS or cesspool
✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
✓ Liquid depth in pit is less than 6"below invert or available volume is less than%day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
✓ Any portion of the SAS;cesspool or privy is below high ground water elevation
N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a
surface water supply
N/A Any portion of a cesspool or privy is within a Zone 1 of a public well
N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well
N/A 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 cotiform 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 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. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails. The system owner should contact
the Board of Health to determine what will be necessary to correct the failure.
E. Large Systems: N/A
To be considered a large system the system must service 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
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.
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system is 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.
Title 5 Inspection Form 6/15/2000 4
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 32 LADY SLIPPER LANE
MARSTONS MILLS,MA 02648
Owner: BRIGGS,PETER
Date of Inspection: JANUARY 3, 2005
Check if the following have been done. You must indicate"yes"or"no"as to each of the following
Yes No
✓ Pumping information was provided by the owner,occupant,or Board of Health
✓ Were any of the system components pumped out in the previous two weeks?
✓ Has the system received normal flows in the previous two week period?
✓ Have large volumes of water been introduced to the system recently or as part of this inspection?
✓ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
✓ Was the facility or dwelling inspected for signs of sewage back up?
✓ Was the site inspected for signs of break out?
✓ Were all system components,excluding the SAS,located on site?
✓ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the
condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum
✓ Was the facility owner(and occupants if different from owner)provided with information on the
proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)has been determined based on:
Yes No
✓ Existing information. For example,a plan at the Board of Health.
✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of
distance is unacceptable)[310 CMR 15.302(3Xb)]
Title 5 Inspection Form 6/15/2000 5
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 32 LADY SLIPPER LANE
MARSTONS MILLS,MA 02648
Owner: BRIGGS,PETER
Date of Inspection: JANUARY 3, 2005
FLOW CONDITIONS
RESIDENTIAL-.(
Number of Bedrooms(design): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms: 440
Number of current residents: N/A
Does residence have a garbage grinder(yes or no): YES
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no): YES
Seasonal use(yes or no): NO
Water meter readings,if available(last 2 years usage(gpd)): WELL
Sump pump(yes or no) NO
Last date of occupancy: PRESENT
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203):
Basis of design flow(seats/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: N/A TANK SHOULD BE PUMPED.
Was system pumped as part of the inspection(yes or no):
If yes,volume pumped: gallons—How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
✓ Septic tank,distribution box,soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no)(if yes,attach previous inspection records,if any)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight tank Attach copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
1985 PERMIT#85-20
Were sewage odors detected when arriving at the site(yes or no): NO
Title 5 Inspection Form 6/15/2000 6
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 32 LADY SLIPPER LANE
MARSTONS MILLS,MA 02648
Owner: BRIGGS,PETER
Date of Inspection: JANUARY 3,2005
BUILDING SEWER(locate on site plan): ✓
Depth below grade: 16"
Materials of construction: Cast iron ✓ 40 PVC _ other(explain)
Distance from private water supply well or suction line:
Comments(on condition of joints;venting,evidence of leakage,etc.):
SEPTIC TANK(locate onsite plan): ✓
Depth below grade: 22"
Material of construction: concrete metal fiberglass polyethylene
_ other(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 PRE CAST
Sludge depth: 20"
Distance from top of sludge to the bottom of outlet tee or baffle: 10"
Scum thickness: 4"
Distance from top of scum to top of outlet tee or baffle: 12"
Distance from bottom of scum to bottom of outlet tee or baffle: 14"
How were dimensions determined: AS BUILT&TAPE
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as
related to outlet invert,evidence of leakage,etc.):
MAIN TANK AT WORKING LEVEL,INLET BAFFLE—OUTLET BAFFLE.NO SIGN OF OVER LOADING OR LEAKAGE.
NOTE:TANK SHOULD BE PUMPED.
GREASE TRAP(located on site plan) N/A
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 tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as
related to outlet invert,evidence of leakage,etc.):
Title 5 Inspection Form 6/15/2000 7
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 32 LADY SLIPPER LANE
MARSTONS MILLS,MA 02648
Owner: BRIGGS,PETER
Date of Inspection: JANUARY 3,2005
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: (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 IS 16"X 2 1"—27"BELOW GRADE,ONE LINE IN—ONE LINE OUT.
BOX IS CLEAN&SOLID,NO SIGN OF OVER LOADING OR SOLID CARRY OVER.
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.):
Title 5 Inspection Form 6/15/2000 8
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 32 LADY SLIPPER LANE
MARSTONS MILLS,MA 02648
Owner: BRIGGS,PETER
Date of Inspection: JANUARY 3, 2005
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type
/ leaching pits,number: 1
leaching chambers,number:
leaching galleries,number
leaching trenches,number,length
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of
vegetation,etc.)
LEACHING IS ONE(1)1000-GALLON PRE CAST PIT,PIT&COVER 32'BELOW GRADE,20"WATER
STAIN LINE AT 2'.NO SIGN OF OVER LOADING OR SOLID CARRY OVER.
CESSPOOLS: N/A (cesspool must be pumped as part of inspectionX 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.):
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.)
Title 5 Inspection Form 6/15/2000 9
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Page 10 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYST ':' "sSPECTION FORM
PART C
!)R,'VLkTION(continued)
Property Address: 32 LADY SLIPPER LANE
MARSTONS MILLS,MA 02648
Owner: . BRIGGS, PETER
Date of Inspection: JANU.lkRY 3, 2005
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.
IT3
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Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 32 LADY SLIPPER LANE
MARSTONS MILLS,MA 02648 .
Owner: BRIGGS, PETER
Date of Inspection: JANUARY 3. 2005
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to groundwater 51 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:
Observation site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation
—T Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
USGS WELL SDW 253 AT 51
BOTTOM OF PIT AT 9'—42' ABOVE WATER.
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spection Form 6/1 i
TOWN OF BARNSTABLE
11
LOCATION - -404'0"' SEWAGE #
VILL GE / /. ASSESSOR'S MAP & LOTS al'1®0�
1£R'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMIT DATE: COMPLLkNCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well 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
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14,E y- 7- A sous es
• LOCATION kOT SEWAGE PERMIT NO.
VILLAGE
I N S T A LLER'S NAME ADDRESS
22229
Sly aTi� �/d/fU! l757i�
R U I L D E R OR OWNER
DATE PERMIT ISSUED
vZ DATE COMPLIANCE ISSUED e5
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DI 60r4 Z- A/6'
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.............OF.... R A . /r
.Appliration for Disposal Works Tonstrurtion ramit
Application is hereby made for a Permit to Construct ( A�®rpair ( ) an Individual Sewage Disposal
System at: �0 T���/.-� F
----....__....
Location- ess
W =..... � wner, Ad ress
.............................. ......... .......--
I . ` V
-
Installer . Address
Tyre of Building Size Lot. .yBL..� eet�'
U Dwelling—No. of Bedrooms_........_. .Expansion Attic ( ) Garbage Grinder (n/m Other—T e of Building No. of persons............................ Showers — Cafeteria
WW Other fixtures ------------------------------------ a6 0''V•--------------------...---------•---••-----._...--•---- ..
Des•gn Flow.............. Q....................gallon p�r ay. l daily flo �3 �lp.n--s--
.
—Liquid capacity�0Sep is Tank D:Dgallons Length___ t .idth . . Diameter ._De th••• ......._.x Disposal Trench—No..................... Width.................... Total Length......G.......... Total leaching area..................'..�q. ft.
Seepage Pit No....../__________-- Diameter..... . Depth below inlet____________________ Total leaching area ' .7isq. ft.
Z Other Distribution box ( ) Dosing tank ( )
'-' if r C 2 �1� 1
a Percolation Test Results Performed by._../',.. c_ .[_ .._.._.._ ..._._�.._...._ ate__...1.... �� .___._.....
Test Pit No. 1....42.__.minutes per inch Depth of Test Pit......Y.A.'----- Depth to ground water.._
0i 4 Test Pit No. 2................minutes per inch Depth of Test Pit......62(.... Depth to ground water....f_a,tany .
a ...........................................................`-••• •.........................•-....--••--••---------............. ._.._.. ....
O Description of Soil T '�l..Q-_ �_hK10D_ A!)^!a .I.W!tL-� '� M 'e� r7.
x `..��----- �og�6t'2 s d � .►!F✓t.3 -f� ,�.d ..-,. o'�..-_ C �,o��. � Cd!1 .IV.
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 IIILE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the oard of health.
igned................. . -- -• .............................................. .....l 1.$�...•-
ApplicationApproved By........ ...C:.... .•• -•-- ................................. --------9 -. ------------
Da
t t e
Application Disapproved for the following reasons-------------------------------•-----•--•--------------••--------------------•--•------------------........_.....
...---••--•---------•-----•--•---------------------•------•--•----------------•-•----------•---•----•---..__..•..-------•--•------•-----------------------------------------------------
Date
PermitNo......................................................... Issued-.......................................................
Date
No................--.....-- FE�.:...
s THE COMMONWEALTH OF MASSACHUSETTS
YW
BOAR® OF HEALTH
"�?.......---- ..
Appl ration for Dingnsttl Works!!®r!epair.(
nntrnrtion rrntit
Application is hereby made for a Permit to. Construct ( ' , ) an Individual Sewage Disposal '
System at:
.........:...: -- ....----.............-----•-----.....-I i.... ......•....... .:.......----••-------•------....----------------•---- ..
Location- nns
' r�' f ✓F 2 .� ��°r........ GYT f...... .....
wr
dress
W - -�---------------------•------... ..------ ...
` ' ........... .........
� Ins aller �' Address '
e of Building �� d
A4
T
U YP g Size Lot��:..._... Lum
Dwelling—No. of Bedrooms.....................................Expansion Attic ( ) Garbage Grinder (Va
Other—T e of Building
a Other—Type g ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Other fixtures dr'\
------------------------
W Desi n Flow.............l`o....................gallons er n per day. Total daily flow__._._...._.._. g�allons.
g ga P .P�'� P Y `ate-- --------------
1:4 f Septic Tank Liquid capacity/O.O a.gallons Length.j.�.:... Width...,S........._ Diameter................ Depth.'-5..........
Disposal Trench=-No..................... Width.................... Total Length.....6............ Total leaching area_.__....._......,..,..s�q. ft.
Seepage Pit No...../.............. Diameter..... Q......_. Depth below inlet.................... Total leaching are�.`?.7r�.'sq. ft.
Z Other Distribution box ( ) Dosing tank
'-' Percolation Test Results Performed by:..�-...t�r!.� . _. ` `� .....
a •-••--•-••-----•--------•------•--...-•---� ............
.a Test Pit No. 1---K2.....minutes per inch Depth of Test Pit...... �......... Depth to ground water.. ......
Test Pit No. 2................minutes per inch Depth of Test Pit...... �___.. Depth to ground water---
......................................................... --C.....------------------- .......................................
O Description of Soil ..::.//
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U Nature of Repairs or Alterations—Answer when applicable................................................................................................
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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
operation until a Certificate of Compliance has been issued by th o rd of health.
igned.............•- ------ ------••-•--------••------- '
Application Approved BY --""" ? ... :.... ........... ------------------------- -•----- . ................
Date i
Application Disapproved for the following reasons:..................................................................... -
Date
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
`..7.OX cW...........OF...... 40 ao W. ..........................
r
Tnrtifiratr of Tuntpliatta
THIS IS TO CERTIFY at he Individual Sewage Disposal System constructed (V) or Repaired ( )
byr�cl ...', .�V- --------------_---- •----:--------------
�, f Installer t
...
has been installed in accordance with the provisions of TI'UE 5 of The State Sanitary Code as de c'bed in the
application for Disposal Works Construction Permit No.__..°.''.-_.__:.. ` V_______________ dated-----__ -_-
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CO TRIBE® AS A ARANTEE THAT THE
SYSTEM WI L UNCTION SATIS ACT RY.
DATE.......... . • =- G +� --••-- Inspector............. ----------------•-•---•-- . ---•--•. ........ ..........
THE C MMONWEALTH OF MASSACHUSETTS
BOARD O'F`,-"HEALTH
�[ / � .f ................OF.�� aT!�"r'� �~ .
NO.G2S. FEE:! +- ..
Disposal 10orka (9 atntrnrtuan antic
1 Permission is hereby granted........ - LU .I•-••-•--••••---••-•----•---•-•--•-----•-•••......•...........................
to Constr' t ((�or,Repair ( ) an Individual Sewage isposal Syst�cn
atNo ' �{a-.� ,Y .�' ..e� l ----------1 ................................................ry e Street
as shown on the-application for Disposala`��orks Construction:_.Permit No.__ �-------------- Dated--__-____-__...... ...........:......
/7-�� � Board of Health 7DATE..------•---• ----....... .......................................
FORM 1255 A. M. SULKIN, INC., BOSTON
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L. . 6Q,C�'. . . ... .
TOP OF FOUNDATION
6 • CONCRETE COVER
CONCRETE COVERS
rp
4"CA ST• IR02I� M Xmr ?rnm�r .
OR SCHEDULE 40 •12'•MAX. '
P.V.C. PIPE 4� SCHEDULE 40 P.V.C.(ONLY)
• PITCH 1/4"PER. PIPE = MIN. LEACH .
PITCH 1/4"PER.FT PIT PRECAST
J
o c .
o INVERT • a LEACHING
` o EL, 6,3,3.: "' INVERT INVERT e . e ; PIT OR
c'< SEPTIC TAN K DI ST. . w
ELkSS?6. Eb,S<, �'9• : _ EQUIV.
a INVERT 7000 BOX
GAL. INVERT 6�va 4
..:.i.: 3/4"T011/2
EtS66 INVERT w o N
• - ELF,, .. :. WASHED
STONE
PROFI LE OF GROUND WATER TABLE
SEWAGE DISPOSAL SYSTEM
NO SCALE ,
SOIL LOG . WITNESSED BY
„DATE TIME.•. . . . • 1-5/1.'1f'f'"?Cr7?WCBOARD OF HEALTH
TEST HOLE I TEST HOLE '2 � s/ j—'1�✓C
• • ..• ., , .. . . . . . . ENGINEER -
ELEV. .,5. . . ELEV. S6 ... . .
/ wood�pgM e!•• o-/ooGsLOfiM T- . . .
DESIGN DATA :
MEt�; Co�Rs-� NUMBER OF BEDROOMS
-TOTAL 'ESTIMATED, FLOW �. v,�.0. . GALLONS/DAY
' [c3iqR�rc .BOTTOM LEACHING AREA 78.,5' . SO.FT. /PIT
• .
v cai�tc5 .�s�r✓a. ��.+�o ` SIDE LEACHING AREA . . . . lB .� . . SO.FT./ PIT
� _ GARBAGE DISPOSAL •. . . . . o, (50 /o AREA INCREASE)
t TOTAL LEACHING AREA : . . . .�6?. SO.FT
PERCOLATION 'RATE . : . . . . . < MIN/INCH
' LEACHING AREA PER PERCOLATION RATES ) 79SO.FT.
i✓4.WATER ENCOUNTERED .
NUMBER OF LEACHING , PITS
APPROVED,. . . . . . . : . BOARD OF HEALTH - . . .. . . . .
,DATE.-.
AGENT OR. INSPECTOR
F? `^
2. G. N EY� i lo.25100 ; 27
N�
C'�STEF
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SANRRiNP�
PETITIONERf ?Z<at/. .G. �F.c-�n/