HomeMy WebLinkAbout0069 MOCKINGBIRD LANE - Health is t! f' <<'f ,.► `! F1
69 MOCKINGBIRD LANE'M: MILLS.
A=013'=017 '"
I
DATE; 3/20/01 ----
PROPERTY ADDRESS:
_-Mars tons-ub11S.a1AAS_ ._„
_-------- 02648-_--------
On the above data, I Inspected the septic aysterfi- at the above address.
This system conslsta of the following;
1 . 1 -1000 gallon septic tank.
2 . 1 -Distribution box.
3 . 1 -1 000 gallon precast lea hint' A4ry the followln8 oondltlona:
Based on my Inapectcfon,
4 . This is title five septic system, ( . 78 Code )
5: The septic -system is in proper working order C 13
_. at the present time.
6. `Pumped the septic tank at time of inspection.
7. Waste water is 42" below the invert pipe of
the leaching pit: .
SIGNATURE
/ Company: Joa•2h_t_ Hecomber_b Son , Inc ,
Address :— Box 66 _____
Centerville H _,_02692-•0066
Phone: 508_775-3978_______
THIS CERTIFICATION OOES NOT CONSTITUTt' A OVARANTY OR WARRANTY
JOSEPH P, MACOMBER & SON, INC,
Tanks•Cesspools•LsachfI#Ids
Pumped i, ;InitaII0
Town Sewer Conneotlon1
P•0• eox 66r5•JJJ8ey1775.641z26JZ_0
�-\ COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 69 Mockingbird Lane
Marstons Mills,Mass.
Owner's Name:Gloria Charnley
Owner's Address:Samr as above RECEIVED
Date of Inspection: 3/2 0/01 , 2 2001
MAR
Name of Inspector: (please print) Joseph P.Macomber Jr.
Company Name: J.P.Macomber & Son Inc. TOWN uF BARNSTABLE
Mailing Address:Box 66 HEALTH DEPT.
CPntt-rV1 1 1 fP -Maac 02632
Telephone Number: rna-77
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:
—/
f t/ Passes
L Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: �� Date:
The system inspector shall submit a copy of this inspectio report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving
authority.
Notes and Comments
****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 page l
t
Page 2 of 1 I
OFFICIAL INSPECTION FORM—
NOT FOR VOLUNTARY
ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 69 Mockingbird Lane
Marstons Mills,Mass.
Owner: Gloria Charnle _
Date of Inspection: 3/2 0 01
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A! yytem Passes: �
ILO 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:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired. The system, upon completion of the replacement or repair,-as approved by the Board of Health, will pass.
Answer yes, no or not determined(Y,N,ND) in the for the following statements. if"not determined"please
explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
ItIe 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:
2
Page 3 of I 1
OFFICIAL INSPECT .,'.)N FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE S 'VAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 69 Mockingbird Lane
Marstons Mills,Mass.
Owner: Gloria Charnley_ _
Date of Inspection: 3 2 0 01
C. Further Evaluation is Requi r. by the Board of Health:
N71 Conditions exist which req . :tether evaluation by the Board of Health in order to determine if the system
is failing to protect public health, s or the environment.
1. System will pass unless B,,..;.j of Health determines in accordance with 310 CMR 15.303(l)(b) that the
system is not functioning manner which will protect public health,safety and the environment:
tto Cesspool or privy is �k 50 feet of a surface water
Cesspool or privy is 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the ird of Health (and Public Water Supplier, if any) determines that the
system is functioning in a ma.. r that protects the public health safe and environment:
Y g P P safety
dD The system has a sept : ;..rik and soil absorption system (SAS)and the SAS is within 100 feet of a
surface water supply or rrit rx to a surface water supply.
The system has a sept k and SAS and the SAS is within-a Zone I of a public water supple.
/I The system has a sept . ...iik and SAS and the SAS is within 50 feet of a private water supply well.
Xd The system has a sept :.k and SAS and the SAS is less than 100 feet but 50 feet or more from a
private eater supple wells ' !ethod used to determine distance
'This system passes if the water analysis, performed at a DEP certified laboratory, for coliform
bacteria and volatile organic c :npounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitro:.;en 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:
3
Page 4 of I 1
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 69 Mockingbird Lane
Mars tons Mi s,Mass .
Owner: Gloria Charnley
Date of Inspection: 3 20 01
D. System Failure Criteria applicable to all systems:
You must indicate"yes" or"no"to each of the following for all inspections:
Yes No/
Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
_ Liquid depth in.cosepeel•is less than 6"below invert or available volume is less than ''/2 day flow
VRequired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped).
_ Any portion of the SAS, cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
_ Any portion of a cesspool or privy is within a Zone I of a public well.
_ Any portion of a cesspool or privy is within 50 feet of a'privak water supply well.
Any portion of a cesspool or privy is less than 100 feet but gr ter than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
__(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:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd•
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
_Zthe system is within 400 feet of a surface drinking water supply
i/ the system is within 200 feet of a tributary.to a surface drinking water supply
7 the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—1 `')or a mapped
Zone lI 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 has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
4
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Page 5 of I 1
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 69 Mockingbird Lane
Marstons Mills,Mass.
Owner: Gloria Charnley
Date of Inspection: 3/20/01
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 pan of this inspection
Were as built plans of the system obtained and examined?(If they were not available note as N/A)
4 _ 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,- eluding the SAS, located on site ?
4 _ Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition
of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum '
Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems ?
The size and location of the Soil Absorption System (SAS)on the site has been determined based on:
Yes no
YExisting information. For example, a plan at the Board of Health.
Determined in the field (if any of the failure criteria related to Pan C At issue approximation of distance
is unacceptable) (310 CMR 15.302(3)(b)J
5
Page 6 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 69 Mockingbird Lane
Marstons Mills,Mass.
Owner: Gloria Charnley
Date of Inspection: 3/2 0/01
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): cd! Number of bedrooms(actual):
DESIGN flow based on 310 CM,R 15.203 (for example: 110 gpd x # of bedrooms)- )b,= Pelw,
Number of current residents:
Does residence have a garbage grinder(yes or no):
Is laundry on a separate sewage systemor no): [if yes separate inspection required)
Laundry system inspected (yes or no):
Seasonal use: (yes or no): ,0
Water meter readings, if available (last 2 years usage(gpd)):
Sump pump(yes or no): z 1/y.O7
Last date of occupancy: ,
COMMERCIAL/WDUSTRIAL
Type of establishment. t)A
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc
Grease rrap present(yes or no):
Industrial waste holding tank present(yes or no):,d),d
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: , Qjf mid
Was system pumped as pan of the inspection (yes or no):
If yes, volume pumped: 1 d gall ns - How was uantit p mped etermined?
Reason for pumping: s.`r! S �'s
TYEE OF SYSTEM
,K Septic tank, distribution box, soil absorption system
L&�2 Single cesspool
4�), Overflow cesspool
Privy
Shared system(yes or no)(if yes, attach previous inspection records, if any)
,L6 Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be
obtained Gom system owner)
o Tight tank 41� Attach a copy of the DEP approval
Other(describe):
Approximate aoe of all components, date installed (if known) and source of information:
Were sewage odors detected when arriving at the site (yes or no):Ilf/c?
6 -
Page 7 of 1 I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 69 Mockingbird Lane
Marstons Mills,Mass.
Owner: Gloria Charnley
Date of Inspection: 3/20/01
BUILDING SEWER (locate on site plan)
Depth below grade: /5"
Materials of construction: cast iron �40 PVC./bother(explain): AW
Distance from private water supply well or suction line: /4`/-
Comments(on condition of joints, venting, evidence of leakage, etc.):
Joints a==Par, tight-`Nn evidence of leakage System is uented
through the house vent.
SEPTIC TANK: (locate on site plan)
Depth below grade:
Material of construction: ncrete metal�fiberglass.;'7 polyethylene
Material of consmjc�l�on:
j�iother(explain)
If tank is metal list age:,(! . Is age confirmed by a Certificate of Compliance (yes or no):,I/, (attach a copy of
certificate) ll ��
Dimensions:Sludge
Sludge depth:
Distance from top of sludge to bonom of outlet tee or baffle: —
Scum thickness:
Distance from top of scum to top of outlet tee or baffle: 0
Distance from bonom of scum to bonAm of outlet tee or ba
Noµ were dimensions determined: -47" /, V D 1,f16
Comments (on pumping recommendations, inlet and outlet tee or baffle con ttion. structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
Pump the septic tank PNzPr_))2-3 pars Inlet & outlet-tees
are inplace- .The tank is structurally sound and shows no
evidence of leakage.
GREASE TRAP (locate on site plan)
Depth below grade: I
Material of construction: l.% concrete4A/ metaId&fiberglass J�Apolyethylen%W4 other
(explain): IV,4
Dimensions: W
Scum thickness: A
Distance from top of scum to top of outlet tee or baffle: �A
Distance from bottom of scum to bottom of outlet tee or baffle: 4
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.):
Gr as trap i c nnt- nrPcant
7
_ I L •
Page 8 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 69 Mockingbird Lane
Marstons Mills,Mass.
Owner:Gloria Charnley
Date of Inspection: 3/2 0/01
TIGHT or HOLDING TANKA/�jtank must be pumped at time of inspect ion)(locate on site plan)
Depth below grade: 0
Material of construction: Aq concrete Af4 metal.4gfiberglass&&Ayolyethylene N other(explain):
d4a
Dimensions: AM
Capacity: 4),4 gallons
Design Flow: AIA gallons/day
Alarm present(yes or no): _,da
Alarm level: A.1,4 Alarm in working order(yes or no):
'Date of last pumping: AM
Comments(condition of alarm and float switches, etc.):
Tight or holding tanks are not- nrt-sPnt_
DISTRIBUTION BOX: present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
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.):
Di sarihutinn hnx ha- nnP 1atara1 Nn eyidenCP nf Snlids
carry over No evi danno o f leafage jntG or 913t of th@ ho
PUMP CHAMBERr t,,fJocate on site plan)
Pumps in working order(yes or no): AW
Alarms in working order(yes or no): 414
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
Pump Chamber is not Present-
r 4
Page 9 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:69 Mocking Bird Lane
Marstons Mills,Mass.
Owner: Gloria Charnley
Date of Inspection:3 20 01
SOIL ABSORPTION SYSTEM (SAS): L/ (locate on site plan,excavation not required)
If SAS not located explain why:
Type/
1O leaching pits, number:
leaching chambers, number: cl
470 leaching galleries, number: )
leaching trenches, number, length: 0
,A:g) leaching fields, number, dimensions:
4)0 overflow cesspool, number: D
,j2L-) ��---- ��innovative/alternative system Type/name of technology:/j I ldN 16
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,
etc.):
Loamy boney soil to medium fine sand.No signs of hydraulic
failure or pon ing.Soi s are dry.Vegetation is normal.
CESSPOOLSAr9 (cesspool must be pumped as part of inspect ion)(locate on site plan)
Number and configuration: X2
Depth—top of liquid to inlet invert: A4$
Depth of solids layer: Id/14
Depth of scum laver:
Dimensions of cesspool: /
Materials of construction: lL'
Indication of groundwater inflow(yes or no):
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
Cesspools are not present,
PRIVY(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.):
Privy is not nrPGPnt
9
Page 10 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 69 Mocking Bird Lane
Marstons Mills, ass.
Owner: Gloria Charnley
Date of Inspection: 3/2 0/01
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.
07
10
• tr Page 11 of I 1 r..
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Propem Address: 69 Mocking Bird Lane
Marstons Mills , ass.
Owner:Gloria Charnlev__
Date of lnspection: 3/20/01
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water-15 L feet
Please indicate (check)all methods used to determine the high ground water elevation:
,fit Obtained from system desi lans on record • If checked, date of design plan reviewed:
se tttn pro er y bservation hole within 150 feet of SAS)
,&)c Checked with local Board of Health-explain:
Checked with local excavators, installers- (attach documentation)
X,10Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Used; Water Cont-rnjrc Map
GahrPty R M; l l izr Model
12/lei/�4
a
Y
i3
11
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1 i
TOWN OF Barnstable BOARD OF HEALTH
SUI)SURFACF SFWAGF DISPOSAL SYSTEM INSPECTION FORM - PART D •- CE11TIF1CATION
r.•..T••.-. r��.t1I.�.-,"rI T1 t.,l•n.T.TITTRTfI T.TT.T•.r5.1-'11Trf 71'RII-•�/n7�IR ATf�'tR�T7 nln nT1R1"RRT�•TT1�TT.l—rr� r•�.. .-. f
-TYPE OR PRINT CLEARLY-
PIIOPERTY INSPECTED
STREET ADDRESS 69 Mocking Bird Lane Marstons M; 11GlpMass
ASSESSORS MAP , BLOCK AND PARCEL .
OWNER' s NAMEGloria Charnley
PART D - CERTIFICATION I
NAME OF INSPECTOR Joseph P.Macomber Jr.
COMPANY NAME J.P.Macomber & Son Inn:
COMPANY ADDRESS Box 66 Centerville,Mass. 02632
Street Town or City State LIP
COMPANY TELEPHONE ( 508I 775 - 3338 FAX ( 508 790 -1578
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposa-, system at
Oecoininendat' ions
his address and that t)►e information reported is true , accurate , .and
omplete as of the time of .-inspection , The inspection was performed and any
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 :
v System PASSED
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
healLh or, Lhe environment as defined in 310 CMR 15r303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form .
System FAILED*
The inspection which I have co acted has found that the system fails to
protect the ptiblic 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 �e, w -� ✓ -d
P S Date
On e copy of this c rt.ification must be provided to the OWNER, the BUYER
Nhere applicable ) and the BOARD OF HEAL1'JI,
* If the inspection FAILED, the owner or""o" orator shall u
P pgrade ' tho system
within one year of the date of the inspection , unless allowed or required
otherwise as provided in 310 CMR 16 . 306 .
partd . doc
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L;b C 0 T ION E W G E PERMIT NO.
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VILLAGE
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INSTA LLER'S NAME i ADDRESS
® U I L 0 E R OR OWNER
DATE PERMIT ISSUED LT
dv
DAT E COMPLIANCE ISSUED
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THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
.............................----------.--.OF..........................................................................................
ApplirFation for Disposal Works C onstrurtiun ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
&Z cC�(1—G �t� G 2 &o% v 7
................_.._..__.................................. ..........---................. .................,..... ....----.....-----------•-..............................-..............
Location-Address or Lot No.
...............
Owner Address
.......................................................
Installer Address
Type of Building Size Lot........?.:U`_'-!.......Sq. feet
U Dwelling—No. of Bedrooms................... .Expansion Attic ( ) Garbage Grinder f1U0
pa, Other—Type of Building _(U.aep............. No. of persons....... ................ Showers ( ) — Cafeteria )
aOther fixtures ---------------------------------•-----................---..............--•------•--------------..........----------------............-•-•-----•......
d
Design Flow..................... .............gallons per person per day. Total daily flow.......23-........._.... _...........gallons.
W Septicq • y ovo b gt � . `� ....... .. Depth7'6`e
M D sposal Trench 1 No. .a ...... Widthns. t.4.-. Total Length....z=-�-�..Total leaching area...
_-. .........sq. ft.
W v /Seepage Pit No.........I.......... Diameter....../z..._.... Depth below inlet......`../......... Total leaching area.Zb3:f...sq. ft.
Z Other Distribution box'(1r� Dosing tank
~' Percolation Test Results Performed by......�:C!t'�!�!? ...� .ne al.................. Date..... � y .............
Test Pit No. 1_ Z...minutes per inch Depth of Test Pit.....XZ......... Depth to ground water...NK ......
fT4 Test Pit No. 2.:` ::minutes per inch Depth of Test Pit......... Depth to ground water........................
Description of Soil-..........b..:-.I.. �`�i�r T� (4.1
-----------••-------- •--•---------------------•--------------------.-.-.-------•--•-•---------.-.•-.-.-_-.------------------•--•-.-•-----
••...................••••.............•--- ......
--------------------------•------------ . ..z••--•-•,«----_7..... - ----------.....------------------------......--------------.........._---_•-
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 iITLL 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b issuL�t and of health.
Siglied.......z_ ....••. •----•. . ----•-•--- ............................... ..........................-....
D to
Application Approved By......--- r.... .....�..... ....................... _ t V . .............
Date
Application Disapproved for the following reasons:.......................................................................................................... -
•-•-••••---•-••--•-•---------•...----•...........•---••----•----•-••-•••................_..._......----.-•-...-•••••••••............_.....-•-•-•---•-........--•••--••-............-•--.....---•••----
Date
PermitNo......................................................... Issued.......-...............................................
— - -- —--- — -1 Date
Flcs..��
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH ,
...---•........ .........................O F..............................._....: ..:... ........_.. ._........_........._...__
Appliratinn for Disposal Works Tonstrudion Vrrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
system at:
G = G", �
........... ... ! ..............................••- -.-....�... .- -
Location-Address
-• •--"-_o_r,..Lot ........• ......... _--•-•_----•-•-
._ /,\
............. �.....................Owner ? ; wrl
................. a-• 3 ••••_? ............_ ......
AdreW
Installer Address
Type of Building Size Lot-?:4!..�' '".........Sq. feet
a Dwelling No. of Bedrooms.__........'...........................:...Expansion Attic ( ) Garbage Grinder A#
ll
aOther—Type of Building >, :.^............... No. of persons___.................... Showers ( ) — Cafeter- )
Other fixtures .......................................
a' ................•_•___...__...__.._..........._-............_.................._.
W Design Flow....................l:L.•_.---..•..._..gallons per person per day. Total daily flow.___-__-3_____'__________________________gallons.
R� Septic Tank—Liquid capacityd_c^:»:.._gallons Length__ .::_ ..'.. Width.. i:'-:''_. _--::,• Diameter__._ ___.__ Depth.._.'_:_`:..._..
Disposal Trench—No..._ .!: ........ Width......:::.: :...... Total Length.____:-::............ Total leaching area...__---::..........sq. ft.
Seepage Pit No........./._._ _ . Diameter......_ :...____.. Depth below inlet_....`?!.......... Total leaching area.' ?:_.�....sq. ft.
Z Other Distribution box (L-) Dosing tank•(=)-
a Percolation Test Results Performed by.... ___.`...._f_ � .�'. .................. Date...-:`Z_-=z ................
Test Pit No. I...::_:?.____minutes per inch Depth of Test Pit.....f__'_./.._._... Depth to ground water_..f-c�:�_"..._.__.
f� Test Pit No. 2...::......:...minutes per inch Depth of Test Pit__........_._....... Depth to ground water._..___..--___....__..
.............. ....................... ......................-................................
Description of Soil............ - - /- -- ,,��� � �<°<,�'4
--•-------- ----- ..........................................................--..........................._.............
v -••• { . y.................-.......... ..._.. _._.._...... .......---------------
W ........................... -•-- f i? ........ .�/ '_._:_..`=:.'a'=",-==- ----• ----•----------------------•----------•----....
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
operation until a Certificate of Compliance has beeq issue the-board of health.
Signed••-...._..-•-•..�. '............................................................' ................................
ae
Application Approved By..........
Date
Application Disapproved for the following reasons-..............................................................................................................
.......................••--------•--•-------•--•---------..._.-----.._._....------------------.....--------------...........................................
Date
Permit No.
:.....................................................�:. Issued.......................................................
Daft
THE COMMONWEALTH OF MASSACHUSETTS—
BOARD OF HEALTH
f�.
OF.....................................................................................
,�' - � t r •. ° �rr#ifirtttp of f��aut�rlittnrr �-
p1.' THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
by............... ....... . ------••--------•-------•-•--•--•---------------------------------------------------•--------...--•-----•---.............-••-•••._....._..._..._
y/,�,. Installer
has been installed in accordance with the pro sions of TITLE r of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No........�"i____�_._:.5'', .... dated................................................
THE'ISSUAN F THIS CERTIFICATE SHALL NOT BE CONSTRUE® -A GUARANTEE THAT THE
SYSTEM WILL TION SATISFACTORY.
DATE....l ....."..'..} Inspector....... ._
----•----•• ..-•-••••-••-•--••-• _. ..__--.............................................................
f
THE COMMONWEALTHOF MASSACHUSETTS
BOARD OF HEALTH
c� r�
No. ;j" FI.......
1.................
Disposal Works Tonutrudi n prruti#
' Permission is hereby granted.. .. __..:..::--................................:..............•--........._...............
to Construct (!�1 -r'Repair ( ) an Individual Sewage D o System
r�*' � - /``- -............:20 ...mar/�i'f,''
Street
as shown on the
/pplic ion for Disposal Works Construction Permit No................ ___ Dated..........................
,f •---- -
Board of Health
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS
1
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. LEGEND
EXISTING SPOT ELEVATION 0„0 ���X'(jOFMCS CERTIFIED PLOT PLAN
EXISTING CONTOUR --- 0 --- o?FINISHED SPOT ELEVATION A E c LoT e-1 - MocK►�1�L3i�D L.tAr..fC-
(�
FINISHED CONTOUR 0 0 /�lA�'`_: �►•!J /� ii L-:�
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No 10951 OIN
APPROVED BOARD OF HEALTH '°9o�FGtSj.Ee�'r�� A
DATE AGENT
SCALE, I " 4c--)-' DATE 7- 2-7. 83
LOREDGE ENGINEEI4ING CO. IN CLIENT
EGISTERE
JO
REGISTERED 83ig4 I CERTIFY THAT THE PROPOSED i
�I NO. BUILDING SHOWN ON THIS PLAN
CIVIL LAND CONFORMS TO THE ZONING LAWS
ENGI EER RVE IDR.®Y� J.Q OF BARNSTAB E, ASS. : ExcPT
712 M A I N STREET CH. ®Yl LI,A:M- ��'�'�' �
HYANNIS, MASS. -7.LTS3 __SHEET,L. OF - - - -
. DATE REG. LAND SURVEYOR
20 FT. Ir►/iv. NOTE = /F E/T.YER TsrES�PT/C TANK DR
LEi4C/• 1,V0 O/T .4RC MORE TAfA:'/ /2"9EL0W
/Q PT. /rl/N. 1RAOE,A 24 01AM ETER CONCRETE COYE.P
S�JALL BF 6-ROeJGHT TD GRA of �,-:;ti EXTRi4
JYEAVY CA 5-r //PON C O VER S.y.4 L L 3E US Ec7
EL- I Uo.5 COV.--A5
A . f
f �jkADE COVER , C'LE,4N SAND
�� • I � t - i: :_�
L/9t//D LEVEL —
= �.
AP�CAST
. //irON PlPl'' f 000 GAL. • • o of ��8 -�/8
SEPTIC TANK D/ST. o e • • • • • s • • • • r a • yyASHFO 57t�NE
♦ r0 t OFFFECT/VC �. • • r
.y • • • DEPTi/ • • • • WA5,YED STONE
? �'' ' ' • • . s e • • • • p • PREC,4ST SEWAGE
i5a.8 x Ts -S-1-1. v/D ...
!h � CLEYAT/O�YS
lY� ► • • • • ♦ • • • ♦ o P/7 OR EQU/V
EL= 85.5 -•�
INYF.RT AT BU/t01NCs �7•S FT. 6 FT D/AJ�f.
Prr�Ac��r-e d90 /l7
/A/LET .S PT/G T.4N/l' �15.0 FT_. � I�- FT VIAM. �� �c SEE TABULtT10/V>�
OtJYLgT SEPTIC TA/VK
/NL,Ef D/SYRI�tIT/ON BOX-- C� FT. . . GROWN 1t�TfiW 7A,04E e,�.>:,a �,,e F'�T
SECT MtV OF �eL f�,rcM oQaP
10dTLETD/3T1T1BllTI4IV BQX 94 .4 F7. uTEAVAGE OIeSP 4A L .SY.ST�JM .5) T'� o r .c�.e ems=
/,yLE'T LPACNIM42 PIT �s9. 5• Fj 8�.5) Ta: suw eA
LEACH/NG PIT TA5UL.4TIOIV - � �4 �.�,
PtZe'SeNT AGFbk•E
- IN 9T74'LLII.IV
D,ES/G/V C1i1TERt�t JCALE DIMENSION.
.: %s' _. DIMENSION. A
0/MEN3/0/V $ 4- f'T.
NU.alBER OF BEDRaOMS 3 DIMENSION C 4 FT. (M!t-j
GARCAGED/SPD.S1{L(Jiy/T IJoi•-1C SOIL. LOG►
TOTAZ. EST/IyfX7^ED FLON/ 3352 GAL.IOAY SOIL TEST./ SOIL 7FST/t2 .SO/L. TE$T
NUMBEr 0,C LCACXlNG PITS_ 1 f^�LEK `jam S erLFY, DATE OF" SO/L TEST J�N� ►o, 4983
17/DE LGACNIA'C. PER PIT lS0.8 Sot fT. %1? L, &T.S. RESULTS iVITNESSED BY Co�+uo2s/ JAto31
9oTTpJ+!LFygCN/NG PER P/T 113. Iso. ,eT. 0ERCO4AT/0N RATLe,�E/ �-SS M1N•//NCK
TOTAC. LEA�td/NG AREA 9 SQ. FT. ' " PlE1tCOLf►T/GN RATE/ 2 T'+A4 M/N.11NCN
?.ESc,4VE L tCHING AREA Sip. FT
° P- 21 1-7
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o�' yGN RSE
No.>.oss 1 o � f; ,- ,•: �,,� FL OREDG�'ENG/N,�RI.i/G CO,I NG.
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SUR .lOB NO: 83144 SHEEP 'L O, 2