HomeMy WebLinkAbout0044 MOUNTAIN ASH ROAD - Health 444 Mountain Ash:Road
Marston'Mills = P J
A= 124- 37 4;
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TOWN OF BARNSTABLE
LOCATION �✓�'��-° S� '�� SEWAGE #
VI LAGE ASSESSOR'S MAP & LOT 42
R1&9�R'S NAME&PHONE NO., d 46 14"C' 9 IS- 2
SEPTIC TANK CAPACITY 71 c—
LEACHING FACILITY: (type) (size)
.NO.OF BEDROOMS
BUILDER OR OWNER A £�C�
PERMTTDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
a
s; c�
O
TOWN OF BARNSTABLE ?
LOCATION M�c( ,5, t -kGl SEWAGE# G/ �/J o 6
VILLAGE / / / •7,J15 ASSESSOR'S MAP&PARCEL "6�[, - :J
INSTALLER'S NAME&PHONE NO. �l pp
SEPTIC TANK CAPACITY
LEACHING FACILITY.(type) #Josize) k X 31,E
NO.OF BEDROOMS
OWNER f1m
PERMIT DATE: ! COMPLIANCE DATE: � L 7 ( 3
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist on
site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within �)
300 feet of leaching facility) /t/ Feet
FURNISHED BY
-
COl
- � _ 37
i �G
Town of Barnstable P#
Department of Health,Safety,and Environmental Services
t Public-Health Division Date
� 0 367 Main Street;Hyannis MA 02601
eAtuvezestE. A / .
MASS.
039.
"rEnenAt" Date Scheduled A" Time Fee Pd•
Soil Suitability Assessment-for S e D'spo l a a
Performed By: Witnessed By:
LOCATION& GENERAL INFORMATION /
Location Address Ow er's ame-r,4,q 4ec.*v 14-"AJ
Flo A-)
Assessor's Map/Parcel: 12W37 Engineer's Name STr:,7N-e�
NEW CONSTRUCTION REPAIR V Telephone# S s 34
Land Use a" "�� ?�e`.�» i.4"� Slopes(%) 'ISurface Stones
Distances from: Open Water Body ft "Possible Wet Area ft Drinking Water Well JS!✓ ft
Drainage Way ft Property Line ft Other ft
.SKETCH:(Street name;dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes)
;
2 C> .
j� CID
6 4 t J,A
x
Patent material(geologic)
OV7-14 A— 114 Depth to Bedrock ?�'�f
Depth to Groundwater: Standing Water in Hole: 'j' Weeping from Pit Face A-J
L•stimaied Seasonal Higii Groundwater
I)�TEItM1NA'1It,N FOYt l!'.ASC)NAE: H. ATEI 'TAB E
Method Used
Depth Observed standing in obs.hole: in. Depth to soil mottles: in.
Depth to weeping from side of obs,hole: in. Groundwater Adjustment ft.
Index Well#_ .. Reading Date:__..-- Index Well level Adj.factor_ Adj..Groundwater Level
PER.C.n A I I►N TE ' nat� `. Ttnae �¢+
Observation"
-- Hole# � Time at 9" .�'" •
Depth of Perc 5 2, Time at 6"
Start Pre-soak Time Q Time
End Pre-soak
Rate Min./inch Z-
Site Suitability Assessment: Site Passed i/ Site Failed: Additional Testing Needed(Y/N)
Original: Public Health Division Observation Hole Data To Be Completed on Back j
Copy: Applicant .
DEEP OSERVATIQN HQE LaG Hole
. _.
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA). . (Munsell) Mottling (Structure,Stones,Boulderes.
Consistency.%Or vel)
7" Ls
DEEP OBSERYATI(1N HtQLE LOG kiole## L
....
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes.
Consistency.° Gravel
It A
DEEP OSSEI2vATION HOLE LQG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes.
Consistency.%Gravel
DEEP OBSERVATION HOLE LOG Hole
Depth from Soil ,Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes.
Con isle c ° Gravel
I
Flood Insurance Rate Maw
Above 500 year flood boundary No—
Yes
Within 500 year boundary No ✓ Yes
Within 100 year flood boundary No. Yes
Depth of Naturally Occurring_Pervious Material
Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the
area proposed for the soil absorption system? Y �
If not,what is the depth of naturally occurring pervious material?
Certification
I certify that on i/ /t (date)I have passed the soil evaluator examination approved by the
Department of Environmental Protection and that the above analysis was performed by me consistent with
the required trainin , ex ertise and experience described in 310 CMR 15.017.
Signature _�' ---- Date A-1f�
No. t Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
ZippYiration for Disposal *pstrm Construction Vrrmit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Lo�ipn Addq s or 1;,otSNQ. �/f/f��l� Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel h2az n ! `�G
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic.Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 ofthe Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by t ' B and of H alth.
e Date
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. Date Issued
1
711
No. ��/ w Fee
t ? "" Entered in co puter.
THE COMMONWEALTH OF MASSACHUSETTS 1 1 Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
",. . 01pplication for 3Disposal *pstem Construction Permit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. /�� //s Owner's Name,Address,and Tel.No.
Assessor's Map/Par `1 �. ` '/ I'N C <j
Installer's Name,Address,and Teh No. Designer's Name,Address,and Tel.No.
I
Type of Building:
Dwelling No.of Bedrooms j Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) L gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to,ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by'this B and of H alth.
•i 'e Date G
Application Approved by ) / Date
Application Disapproved b Date
for the following reasons
Permit No. Date Issued
� TIT I COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired Upgraded( )
Abandoned( )by A)
at has been cons acted in acco nce
with the provisions of Title 5 and the for Disposal System Construction Permit N d ed S
Installer Designer �--�
#bedrooms Approved den flOWA/ / gpd
The issuance of this permit hall not be construed as a guarantee that the system will funct s e as gn�d.
Date ] Z Inspector
- - --------------------------------------------------
---------------------------------- --
No. v THE COMMONWEALTH OF MASSACHUSETTS Fee
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Disposal 6pstem Construction permit
Permission is hereby granted to Construct( ) Repair(,/) Upgrade( ) Abandon( )
System located at /1!1 <0 4/ W X L �
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construeftion-must be
completed within three years of the date of this permit. '
Date j Approved by
i,
Town of Barnstable
°FINE TpN� Regulatory Services
Richard V. Scali, Interim Director
1 , STAB , * Public Health Division
9 MASS. g
`bAr i639. s Thomas McKean, Director
FD MA'S
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Homeowner Certification Form for Alternative Systems
Property Address: Ion A,
Assessor's Map\Parcel: a
Property Owners Name: 1 [vt✓1c� C I-zA L /U
In accordance with Massachusetts DEP alternative system approval letters, the following certification
information is required by the Owner of record. The Owner of record must place an "x" in the
applicable box next to each line certifying the information.
Yes N\A
❑ I have been provided a copy of the Title 5 I/A technology Approval letters.
(15 page Standard Conditions letter and the specific technology letter)
Z ❑ I have been provided with the Owner's Manual
❑ I have been provided with the Operation and Maintenance Manual
❑ For Systems installed under a Remedial Use Approval, I agree to fulfill my
responsibilities to provide a Deed Notice as required by 310 CMR 15.287(10)
and the Approval
Z ❑ For Systems installed under a Remedial Use Approval, I agree to fulfill my responsibilities to
provide written notification of the Approval to any new Owner, as required by
310 CMR 15.287(5)
❑ If the design does not provide for the use of garbage grinders, the restriction is understood
and accepted
❑ Whether or not covered by a warranty, I understand the requirement to repair, replace, modify
or take any other action as required by the Department or the LAA, if the Department or the
LAA determines the System to be failing to protect public health and safety and the
environment, as defined in 310 CMR 15.303
agree to comply with all terms and conditions above.
roperty wners rinte ,nam
Pro rty wn rs' atu Date
e: This form must a su mitted along with the septic s stem disposal works permit
application for all I\A systems including new construction, repairs\upgrades, with and
without aggregate (stone) and with conventional design criteria or credited design
criteria.
Q:\Septic\IA homeowner certification.doc
Town of Barnstable
Opt"E lO�y'Y Regulatory Services
o�
Richard V. Scali, Interim Director
saxrrsrns
. $ Public Health Division
'i639 ��
'TFfl 39 Thomas McKean, Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer & Designer Certification Form
f
Date: �� Zo 13 Sewage Permit-9
- Assessor's Map\Parcel l Z 3-7
Designer: Installer: %eAt,691 1
Address: 9 Z_ A- Address: r79_5�lfi,��G`�
On g aeDlig �/� AZi—XV ti was issued a permit to install a
(date) (installer)
septic system at :qq P4 v*- `�' 1 /t-5 14 (F-"b based on a.design drawn by
(address)
A. R A-1-5 PE dated l 4 z a i 3 . .
(designer)
�I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank. Strip out (if required) was inspected and the soils
were found satisfactory.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of,the septic system) but in accordance with State & Local Regulations. Plan revision or
certified as-built by designer to follow. Strip out (if required) was inspected and the soils
were found satisfactory.
✓I certify that the system referenced above was constructeddbn Adrhpllance with the terms of
the IAA approval letters (if applicable)
s a is Signature) ��xh4�p4xMp 6{
(Designer's Signature) (Affix D igner s Stamp Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH D€VISION. CERTIFICATE
'OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
QASeptic0esiper Certification Form Rev 8-1.4-13.doc
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TABLE 2:TRENCH SIZING
Number of Chambers in Aggregate-Free Trench Systems(See note below for minimum requirements)
n Percolation 330 GPD Design Flow/3 Bedrooms or Less 440 GPD Design Flow/4 Bedrooms 550 GPD Design Flow/5 Bedrooms
O Soil Class Rate
O (min/in) HC/HC ISI 3050/ HC/HC ISI 3050/ HC/HC ISI 3050/
W Equalizer 24 Equalizer 36 STD/STD SldeWinder SC-740 Equalizer 24 Equalizer 36 STD/STD SldeWinder SC-740 Equalizer 24 Equalizer 36 STD STD SldeWinder SC-740
w 1.5'Wide 2'Wide SW T Wide 1.5'Wide 2'Wide SW 3'Wide 1.5'Wide 2'Wide SW T Wide
3'Wide 53"Wide 3'Wide 53"Wide 3'Wide 53"Wide
Trench Trench Trench Trench Trench' Trench Trench Trench Trench Trench' Trench Trench Trench Trench Trench'
< 5' 15 v12 r11 10M � 16h, 219F
o class I Sandy, 6 16 12 12 10 9 21 16 16 13 11 26 20 20 17 14
< sands /tea 7zs' 16 ' { 13 :_ �12- '. y 10 } ' .'21 174.;: i6 14 12"", „i 26 p21 "20 �fi 17fr1,4
m 8 17 13 13 11 9 22 17 17 14 12 27 22 21 18 15
14 ':. i12?' ,j'0 24 ,k' 19 t 18 16 `. 13" 30 x:s24 y� 23` Fi,19
3 6 18 14 14 12 10 24 19 18 16 13 30 24 23 19 16
?' 518 ±i 1.4r 14 t .12s. 1,0, a24t19 :.. 18i i ,16,:; 13 30 JN24 ,'1 'k 23x19v i. is
1 class II 1 8 18 14 14 12 10 24 19 18 16 13 30 24 23 19 16
p - Sandy "` 1A`. ' ';1. ,4,'� �14,_'„ " ',12..' � 11:0:¢.� -.:24s '�--,"19 ; 18,. F�ac16 f13- a"30 "° 24'x`,
O Loams, (. -' s,- - -
N Loams 15 19 15 15 13 11 26 20 20 17 1 14 32 25 25 21 1 17
- � - ,: s-20: ��'y�20 . " .I�' 16��+si� .. 16�:: ��fs13��f " 11; ��,r'27 ,,:wi22 c�'_'= 21��.�4' 18�9 f `15,'• � k.34 .. �27;�;,:'�° 26; :��a22yh; �'�18
w 25 27 21 21 17 15 36 28 27 23 19 45 35 34 29 24
rn _
4
.30 �a 23 v rc -54° 3 , f,�41Jn f 3529
a 15 29 23 22 19 16 39 31 30 25 21 48 38 37 31 26
CL �'� '20 i . .�':32 . 25 20,`t 17 r 42 s,.5 33 r 4...32 :' 27.£
w
Class III 25 33 26 25 21 18 43 34 33 28 23 54 43 41 35 29
SutyLoams: � 37 v 29 ' 28 X-�24. � 20bo `4939x38: '': a` 32r 26,;`# 6j„ 9n49�r 47t. f393k.. 33
m 40" 43 34 33 28 23 57 45 44 37 31 71 56 54 46 38
o .60,* u' 7156 54, 4fi.; L3$ 94s 75 72 ', 61 u 51„ 118 94h90. 76z; �63#,
s
,. .. a
C: Class IV
m Clays,Silty 60" 71 56 54 46 38 94 75 72 61 51 118 94 90 76 63
N Clay Loams
(D
O
The ISI 3050/SC-740 chamber must be backfilled with 1"-2"of stone along the sidewalls to prevent soil intrusion through the sidewall openings.
w **Applies only to the upgrade of existing systems.
w
a NOTE:For new construction,no system shall be designed and constructed with a soil absorption system area of less than 400 square feet of actual chamber bottom and sidewall area.The
a minimum number of chambers required for new construction are listed below:400 sf/(Effective leaching area of chamber based on table in item II (6)of Title 5 Approval x Chamber length)
C
a 1.Equalizer 24 chamber.400 sf/(2.3 sf/If x 8.33 If)=21 chambers;2.Equalizer 36 chamber.400 sf/(2.8 sf/If x 8.33 If)=18 chambers;3.Standard chamber.400 sf/(4 sf/If x 6.25 If)=16
chambers;41 High Capacity chamber.400 sf/(4.5 sf/If x 6.25 If)=15 chambers;5. Infiltrator 3050/SC-740 chamber.400 sf/(8.2 sf/If x 7.12 If)=7 chambers
0
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-- COMMONWEALTH OF MASSACHUSETTS 11 ,
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
.�� ■_ECEIVED
350 MAIN STREET
WEST YARMOUTH,MA MAR 2 12002
LZC1FjUU 508-775-2800
TOWN OF BARNSTABLE
HEALTH DEPT.
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM - -
PART A M
CERTIFICATION
MAP 124 PAR 037 P
Property Address: 44 MOUNTAIN ASH ROAD LO --
MARSTONS MILLS,MA 02648
Owner's Name: TED ALENCE
Owner's Address: 44 MOUNTAIN ASH ROAD 5
MARSTONS MILLS,MA 02648 2
Date of Inspection MARCH 7,2002 O ��
Name of Inspector: (please print) JAMES D.SEARS PARCEL L.
Company Name: A&B Canco LOT
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:
X Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: /13 - a 2
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd
or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.
The original should be sent to the system owner and copies sent tot he buyer,if applicable,and the approving authority.
Notes and Comments
INSPECTOR AND BOARD OF HEALTH MET. LEACHING IS AT LEVEL TO PASS.
LEACHING IS NEAR ITS LIFE SPAN.
****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
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 44 MOUNTAIN ASH ROAD
MARSTONS MILLS,MA 02648
Owner: ALENCE,TED
Date of Inspection: MARCH 7,2002
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes: X
I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
INSPECTOR AND BOARD OF HEALTH MET.LEACHING WILL PASS.LEACHING IS
NEARING ITS LIFE SPAN AND NEARING FAILING.
B. System Conditionally Passes: N/A
_ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.
The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"
please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,
exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing
tank is replaced with 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: 44 MOUNTAIN ASH ROAD
MARSTONS MILLS,MA 02648
Owner: ALENCE,TED
Date of Inspection: MARCH 7,2002
C. Further Evaluation is Required by the Board of Health: N/A
_ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is
failing to protect public health,safety,or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or 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 l 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 44 MOUNTAIN ASH ROAD
MARSTONS MILLS,MA 02648
Owner: ALENCE,TED
Date of Inspection: MARCH 7,2002
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
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded
or clogged SAS or cesspool
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/z day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
X Any portion of the SAS,cesspool or privy is below high ground water elevation
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 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 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 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 44 MOUNTAIN ASH ROAD
MARSTONS MILLS,MA 02648
Owner: ALENCE,TED
Date of Inspection: MARCH 7,2002
Check if the following have been done. You must indicate"yes"or"no"as to each of the following
Yes No
X Pumping information was provided by the owner,occupant,or Board of Health
X Were any of the system components pumped out in the previous two weeks?
X Has the system received normal flows in the previous two week period?
X Have large volumes of water been introduced to the system recently or as part of this inspection?
X Were as built plans of the system obtained and examined?(If they were not available note as N/A)
X Was the facility or dwelling inspected for signs of sewage back up?
X Was the site inspected for signs of break out?
X Were all system components,excluding the SAS,located on site?
X Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the
condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum
X Was the facility owner(and occupants if different from owner)provided with information on the
proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)has been determined based on:
Yes No
X Existing information. For example,a plan at the Board of Health.
X Determined in the field(if any of the failure criteria related to Part C is at issue approximation of
distance is unacceptable)[310 CMR 15.302(3)(b)]
Title 5 Inspection Form 6/15/2000 5
Page 6 of 1 l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 44 MOUNTAIN ASH ROAD
MARSTONS MILLS,MA 02648
Owner: ALENCE,TED
Date of Inspection: MARCH 7,2002
FLOW CONDITIONS
RESIDENTIAL
Number of Bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms: 330
Number of current residents: 3
Does residence have a garbage grinder(yes or no): NO
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no): YES
Seasonal use(yes or no): NO
Water meter readings,if available(last 2 years usage(gpd)): WELL WATER
Sump pump(yes or no) NO
Last date of occupancy: PRESENT
COMM ERCIALANDUSTRIA L
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
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: gallons—How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
X Septic tank,distribution box,soil absorption system
Single cesspool
Overflow cesspool
Privy
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:
UNKNOWN
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: 44 MOUNTAIN ASH ROAD
MARSTONS MILLS,MA 02648
Owner: ALENCE,TED
Date of Inspection: MARCH 7,2002
BUILDING SEWER(locate on site plan): N/A
Depth below grade:
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): X
Depth below grade: 15"
Material of construction: X 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: 1,000 GALLON PRE CAST
Sludge depth: 2"
Distance from top of sludge to the bottom of outlet tee or baffle: 28"
Scum thickness: 0"
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: 18"
How were dimensions determined: ASBUILT AND 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.):
TANK AT WORKING LEVEL.TANK AND COVERS 15"BELOW GRADE. INLET TEE,OUTLET TEE.NO
SIGN OF OVERLOADING.
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: 44 MOUNTAIN ASH ROAD
MARSTONS MILLS,MA 02648
Owner: ALENCE,TED
Date of Inspection: MARCH 7,2002
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: X (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.,):
DISTRIBUTION BOX IS 16"X16",Y BELOW GRADE.ONE LINE IN,ONE LINE OUT.BOX IS GOOD BUT
OLD.COVER WAS BROKEN,REPLACED COVER AT TIME OF INSPECTION.NO SIGN OF OVERLOADING.
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: 44 MOUNTAIN ASH ROAD
MARSTONS MILLS,MA 02648
Owner: ALENCE,TED
Date of Inspection: MARCH 7,2002
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
Type
X 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 1,000 GALLON PRE CAST PIT.PIT IS 42"BELOW GRADE WITH COVER AT 25".
WATER LEVEL HIGH IN PIT.WATER LEVEL IS 9"BELOW INLET.NOTE PIT IS NEAR FAILING.
CESSPOOLS: N/A (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation etc.):
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
Page 9 of I l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 44 MOUNTAIN ASH ROAD
MARSTONS MILLS,MA 02648
Owner: ALENCE,TED
Date of Inspection: MARCH7,2002
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.
Z Zck
yj
� 7
O
c
Title 5 Inspection Form 6/15/2000 10
Page I I of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 44 MOUNTAIN ASH ROAD
MARSTONS MILLS,MA 02648
Owner: ALENCE,TED
Date of Inspection: MARCH 7,2002
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to groundwater 53.3 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
X Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
USGS WELL DATA
5DW 253 53.3' ZONE C 8.7' ADJUSTED 44.6'
l
4
UJ G S
S3 .3
Title 5 Inspection Form 6/15/2000 11
�s
Conunonwealth of Massachusetts
Executive Office of Enviromlental Affairs
kip Dept. of Environmental Protection
John GradOne winter Street Boston Ma. 02108
' D.E.P. Title V Septic Inspector
P.O. Box2119
Teaticket, MA 02536
WILLIAM F.WELD (508)564-6813
Governor
ARGEO PAUL CELLUCCI
Lt.Governor 1 2 i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 1
PART A CERTIFICATION O RECEIVED
OCT 2 0 19g 199
Property Address: 44 Mountain Ash Rd.Marstons Mills Lot 37 Address of Owner: pia
Date of Inspection: 10/16/97 (If different) TD H0IBARNSTAB,
Name of Inspector: John Graci Gerilyn Plno HDEPT.
I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000) 4
Company Name,Address and Telephone Number:
lr
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
Conditional) Passes code 310 CMR 16203.My findings are of how the system Is
y performing at the time of the Inspection.My inspection does
_ Needs F the Evaluation By the Local Approving Authority not Imply any warrentyor guarantee of the longevity ofthe
Fails septic system and any of Its components useful life.
Inspector's Signature: Date: 10116197
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 04n7)97)
One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 44 Mountain Ash Rd.Marston Mills Lot 37
Owner: GerilymPino
Date of Inspection:10116197
_ Sewaae backup or.breakout.or. hicih.static water level observed.in.the distribution 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 usedto 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 10 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.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clugydil
cesspool.
SAS is in hydraulic failure.
(revised 04127)97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 44 Mountain Ash Rd.Marston Mills Lot 37
Owner: Gerilyn Pino
Date of Inspection:10116/97
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
public health and safety and the environment because one or more,of the following conditions exist:
Yes No
the system is within 400 feet of a surface drinking water supply
the system 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 04127197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECLIST
Property Address: 44 Mountain Ash Rd.Marston Mills Lot 37
Owner: Gerilyn Pino
Date of Inspection:10116197
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
_c_ — 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)[15.302(3)(b))
(revised 04127197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 44 Mountain Ash Rd.Marston Mills Lot 37
Owner: GerilynPlno
Date of Inspection:10/16/97
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 3W g•p.d./bedroom 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):
nfa
Sump Pump(yes or no): No
Last date of occupancy: nia
COMMERCIAL/INDUSTRIAL:
Type of establishment: nia
Design flow.o 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: nra
Last date of occupancy: nra
OTHER:(Describe) rda
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
unkown
System pumped as part of inspection: (yes or no)No
If yes,volume pumped:0 gallons
Reason for pumping: rda
TYPE OF SYSTEM
x Septic tank/distribution box/soil absorptions system
Single cesspool
Overflow cesspool
f 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:
s1986
Sewage odors detected when arriving at the site: (yes or no) No
(revised 04127197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 44 Mountain Ash Rd.Marston Mills Lot 37
Owner: CerilynPlno
Date of Inspection:10f16197
SEPTIC TANK: x
(locate on site plan)
Depth below grade: 2'
Material of construction:x concreate metal FRP_Polyethylene_other(explain)
If tank is metal, list age o . Is age confirmed by Certificate of Compliance No (Yes/No)
Dimensions: Lee^H5•r•w4'l0"
Sludge depth:g
Distance from top of sludge to bottom of outlet tee or baffle:0
Scum thickness:a
Distance from top of scum to top of outlet tee or baffle:e"
Distance form bottom of scum to bottom of outlet tee or baffle:0
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 sre structurally sound.Recommend pumping system now and then maintained every year.
GREASE TRAP:
(locate on site plan)
Depth below grade: rda
Material of construction: _concrete_metal_FRP_Polyethylene_other(explain)
Dimensions: rda
Scum thickness:He
Distance from top of scum to top of outlet tee or baffle:rda
Distance from bottom of scum to bottom of outlet tee or baffle: rda
Date of last pumpingn,fa
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.)
rda
BUILDING SEWER:
(Locate on site plan)
Depth below grade: re^
Material of construction: cast iron x 40 PVC_other(explain)
.Distance from private water supply well or suction line?o-
Diameter: 4••
ramments: (conditions of joints,venting,evidence of leakage,etc.)
(revised 04127f97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 44 Mountain Ash Rd.Marstons Mills Lot 37
Owner: Gerl"Pino
Date of Inspection:10116197
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade: rda
Material of construction:_concrete_metal_FRP_Polyethylene—other(explain)
Dimensions: We
Capacity: nla gallons
Design flow: rda allons/day
Alarm level:_nla Alarm in working order?_Yes_No
Date of previous pumping:
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
nfa
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert: nia
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box etc.)
Ne
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.)
rda
,s
pevlaed 04r171971
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 44 Mountain Ash Rd.Marstons Mills Lot 37
Owner: Cerilyn Plno
Date of Inspection:10116197
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:
Na
Type:
leaching pits, number: 1,0W gallon leach pit _
leaching chambers, number:rue
leaching galleries,number: nla
leaching trenches, number,length: nla
leaching fields,number, dimensions:Na
overflow cesspool,number:Na
Altetnate system: Na Name of Technology:_Na
Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
The leach pit Is structurally sound and functioning properly.It was 3M full and had solids In It Recommend pumping every year.
CESSPOOLS:_
(locate on site plan)
Number and configuration: Na
Depth-top of liquid to inlet invert: Na
Depth of solids layer: Na
Depth of scum layer: Na
Dimensions of cesspool: Na
Materials of construction: Na
Indication of groundwater: Na
inflow(cesspool must be pumped as part of inspection)
Na
Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
Na
PRIVY:
(locate on site plan)
Materials of construction: Ida Dimensions: rue
Depth of solids: Na
Comments:(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.)
Na
(revised 0427)97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
44 Mountain Ash Rd.Marstons Mills Lot 37
Gerilyn Plno
10115197
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)
rr SIC K
IS
3
i
d `
irevlaed O4r27197) Page ! of 10
y
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
44 Mountain Ash Rd.Marstons Mills Lot 37
Gerilyn Plno
10116197
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
(revised04127197) page 10 of 10
� ��
TOWN OF BARNSTABLE
LOC:A YON �*'4 1'u[ln"�t a 3�'� e SEWAGE 46— 6*77
VILLAGE % f7lL� ASSESSOR'S MAP Cz LOT-P 2,q
q INSTALLER'S NAME & PHONE NO. �} 2t/ l/ t?c-_S
I
..SEPTIC TANK CAPACITY
a
LEACHING FACILITY:(type) ��,.� (size) 6_
NO. OF BEDROOMS -3 PRIVA�T�E WEL OR PUBLIC WATER
BUILDER OR OWNER //� , �/ /J o 4VIt"I/_
DATE PERMIT ISSUED:
DATE . COMPLIANCE ISSUED: Age,
VARIANCE GRANTED: Yes No
� .L" � � ti
� �G
,� S
R
� _ _�
Department of Environmental Management/Division of Water Resources
WATER WELL COMPLETION REPORT
�f WE �
WELL LOCATyION_ 6 3�
Addresses/^L17�'-7-����/ ,!/yX/�j��(/�
City/Townes///1i111�
G.S.Quadrangle Map
Grid Location `-
Owner � .J,
Address A,
WELL USE CONSOLIDATED WELL
Domestic 91 'p'ublic ❑ Industrial ❑
Type of Water-bearing Rock
Other
Water-bearing Zones
Method Drilled 1) From To
04+ f3 2) From-To-
Date Drilled /v 3) From To
4) From-To-
CASING �J �/ Depth to Bedrock
Length �,� • Diameter o`
Type UNCONSOLIDATED WELL
STATIC WATER LEVEL Water-bearing Materials
Feet below land surf c/+ 9s Sand: fine❑ medium u—coarse 0
Date measured 7 . Gravel: fine❑ medium❑ coarse❑
r
Screen:
GRAVEL PACK WELL
Slot# 10 length % from / to
Yes El No
No oe
V- Split Screen (or 2nd screen)
WATER QUALITY TESTS MADE Slot# length from to
Chemical ❑ Biological Depth To Bedrock
PUMP'TEST
Drawdown feet after pumping days hours at GPM.
"How measured Recovery feet after hours.
LOG of FORMATIONS COMMENTS: (On well or water)
Materials From To
4, 3
—11w7 �r ✓DfRILLER I y
i ir�d J rt r F i r m,;�0�' �� YTAddress ��/ 9�54-'-4d-477 \
city2.0%;Ae �'/ �..
Registration No. 1p A5
` Ci' �� Aerator s ignature
Please print um y BOARD OF HEALTH.COPY 2510I to-n-8071o1
ASSESSORS MAP NO: �Z
NoA.b 6�� PARCEL NO... 3� 7 �
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH .�E51C',NINC, ENGINEER MUST SUPERV
NSTALLATION AND CERTIFY IN WRITi
_...-- .............OF..........��-,p�;,li- .......
►.� —YbTEM WAS INSTALLED IN STR
ACCO NCE TO PLAN.
ApplirFation fur Uhip ial irk- nr, raartUan rmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System. .
�. -
Lo n•Address/
or Lot No.
�
_.�
er Address
w �.
Installer Address
Q Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms...
............. Attic Garbage Grinder (--I—
Other—T e of Building -_-. ..t No. of persons.........� ........... Showers Cafeteria-
QOther fixtures ..--•-•-•-----------. ---'--•-----'•--'-•-•----•---------•--'---•------------•---------------------•------------
Design Flow___._.s, �,........................gallons per person per day. Total daily flow_._..__Sr'_ ..............gallons.
w 3
9 Septic Tank—Liquid capacity/g;��gallons Length................ Width................ Diameter---------------- Depth................
w Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area--------------------sq. ft.
x
3 Seepage Pit No-------f---------- Diameter-_-_- C___ Depth below inlet.....- A... Total leaching area..................sq. it.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by----AAA-ems___ Gt. '.......t------------------- Date---. - ---. ------
04 '
Test Pit No. Ls _ . .......minutes per inch Depth of Test Pit-__-_ZJ. ... Depth to ground wate _-_____--_-------------
f=, Test Pit No. 2.Z.........minutes per inch Depth of Test Pit......12.._.... Depth to ground water________________________
a --------------� f------- T
O Description of Soil....... ����— --•---•� 7-` 1--- �� .....................................
------------ -----------------•-
x
w
VNature of Repairs or Alterations—Answer when applicable.----------------------------------------------------------------------------------------.......
Agreement:
The undersigned agrees to install the aforedescri Indivi a Sewage Disposal System in accordance with
-mrr1�.^ t,
the provisions of l T� �of the State Sanitary The unde ther agrees not to place the system in
operation until a Certificate of Compliance has be iss h _
Signe -
-- - --------
/Date
Application Approved BY t .. ......-•--• /`� t-- 6
Date
Application Disapproved for the following reasons:.._._
............................................. ............................................................
---...------'--•-------•---------------------•-------•--•--'-••--'----•-------------------••--•---------•--.-'-'•--'----------•------•--------------...................................................
Permit No........ -------------- Issued......................... ... Date -----
Date
engineering inc.
civil engineers & land surveyors
October 22 , 1986
Town of Barnstable
Board of Health
Town Hall
Hyannis , Ma. 02601
Re: Crocker Dwelling
Lot 37 Mountain Ash Rd.
Dear Members of the Board:
This letter is to certify that the septic system and well for Lot
37 Mountain Ash Road, Marstons Mills were installed properly and in
accordance with the design plan and complies with the variance of
145 ' from existing wells on lots 19 & 38 as granted by the Board of
Health on July 1, 1986 .
Respectfully,
Rob rt E. Raymond & R.P.L.S.
60 east falmouth highway, east falmouth, ma. 02536 (617) 540-0354
L � 1
No. •�? GJ FEs.....1.......................
THE COMMONWEALTH OF MASSACHUSETTS
_ BOARD OF HEALTH
(J. .........OF..........
Applirtation for Disposal Works
Toustrurtiou tirrmit
Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal
System at
w .7
Aadress / or Lot No.
-- ------ ---
Al
C......-�C..�
a9w er Address
5__a �.... , ... .•-__._.. ••Installer �.... a..................... ..................................................
Instal Address
Q Type of Building rr�� Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms................\.......................Expansion Attic.'r""') Garbage Grinder
aOther—Type of Building .... '-' .- ...... No. of persons...................... Showers (t ) — Cafeteria
Otherfixtures --------•-----------------------------•----•--•-------'•-•---•--•------------- -
W
Design Flow......�r,,) _..----.-__-_------__gallons per person per day. Total daily flow....... .....................gallons.
Septic Tank—Liquid capacity✓J 49allons Length................ Width................ Diameter................ Depth................
Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit---',Fo ---------- Diameter..... Depth below inlet....... •-... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing�tank ( ) �--
Percolation Test Results Performed b /�'z 1 .__..�,`'-.he. ........................... Date.... �' .............
Test Pit No. 1 '._..____minutes per inch Depth of Test Pit-----13..�... Depth to ound Ovate ____ ____________-
Lz, Test Pit No. 2 -..........minutes per inch Depth of Test Pit......�.J.------- Depth to ground water......................
y...- t
O Description of Soil.------0 -`2--- ,"�. �"...-�• ---- -- � .......................� c�..,� 4 rif-. - -
-- -.-
x 1`�'
U -••••••--•---•--------------•--••-----.....•-------••••--••--------•--••--•--•--••-••••••--...•-•-•--•--•-...•-•--•-•••••......••-••-•-•-••--•--
W ••-•------------------------••---•••••---•----------------•---••-•-•--•••----...------••••••-•••-•-•---••-•----•-------------•-------•••---••---•--•-••-•-•-•-•-•••••...••••••-••-••......--••-•---•-••-
V Nature of Repairs or Alterations—Answer,when applicable.______•______________________•-_-_.----__-____.____.-.--________-____-__________....__.__...__-
•-•---------------------------•----••-----••----•••----•---••--•-••-•--•••-•-•-•--•-•.......••-•----•••-••••---••---------.._...-----•----•••-•••-•--•-•-----•••-•--•-•••••--•-........................
Agreement:
The undersigned agrees to install the aforedescri Indivi Sewage Disposal System in accordance with
the provisions of T os, the State Sanitary The unde tier agrees not to place the system in
operation until a Certificate of Compliance has be iss r h y
Signe -- ----------- -......................................... ................................
/Date
Application Approved By-•-•-•1 f?^Xt- . --..:. --.... ...---•--....-•---------•-•--•--------------- -•---t f t.f-.t1.L...---•------
Date
Application Disapproved for the following reasons:----•-------....-•-------•-•--•--•--•--••---•-------•-----------------------------------------------------------
.................................................-........................-..............................................................................................................................
Date
PermitNo............�.__�A__---- ........ Issued......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
i 1-V..
(9rdifiratr of TontpliFamr
1 THIS IS TO CERT FY,That the IndividtiaLSewage Disposal System constructed ( L.Jxrr Repaired ( )
- t/ lC
Install
has been insmiled in accordance with the provisions.of TITLE j of The State Sanitary Code as eAcxibed in the
application for Disposal Works Construction Permit No.....c-T� ^_-----G`?.P. dated_.--. -_��/----�.------------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GU RANTEE THAT ifHE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE........ ........ •---••--•••-----•- Inspector..-•--• ..............................................................
✓ lZ� �� THE COMMONWEALTH OF MASSACHUSETTS
BOARD_ OF HEALTH
i
NO. FEE................,
Disposal Works Tonotruct on Vrrmit
Permission>ol'iereby granted ................-...................................................................
to Construct ( ) or Repair ( an Individual Sewage Disposal Sy tem
_A � -• .....J5.7------_----------M....................................... ry ---------------•-----------
as shown on the application for Disposal Works Construction Permit No��__�27-- DD�at�ed._: _./___,_.4........................
�---
DATE J ( Board of Health
FORM 12HOBBS WARREN, INC.. PUBLISHERS
i
i S
a
ACCESS COVER'S MUST BE WITHIN INSPECTION 9" MINIMUM. INVERT ELEVATIONS : DESIGN CR I TER I A : GENERAL NO TES :
6" OF FINISH GRADE PORT 3 MAXIMUM COVER 95.0 DESIGN FLOW:
FIRST 11\V� I01 .07 2• TO INVERT AT BUILDING:
LEVEL INVERT /N SEPTIC TANK: 93. 75 3 BEDROOMS AT IlO G.P.D. PER I. THIS PLAN IS FOR THE DESIGN AND CONSTRUCTION
BE INVERT OUT SEPTIC TANK: 93.5 BEDROOM EQUALS 330 G.P.D. OF THE SEWAGE DISPOSAL SYSTEM ONLY.
4" DIAM PIPE CLEAN SAND BACKFILL INVERT IN DIST, BOX: 93. 37 NO GARBAGE GRINDER 2. VERTICAL DATUM /S ASSUMED. FOR BENCH MARKS
RO
lo I
I I/ - AROUND AND 2" OVER CHAMBERS INVERT OUT DIST. BOX: 93•2 SET. SEE SITE PLAN.
95.0 93.5 93.2F7:1-
93.75 BAFFCE 93.37 ��� 92.92
GAs ° 92.0 INVERT I N L EACH CHAMBER: 92.9
LOCUS 0�� � 3 OUTLET SEPTIC TANK REQUIRED:
16 H GH CAPACITY INFILTRATOR BOTTOM OF LEACH CHAMBER: 92.0 330 G.P.D. X 200M - 660 GAL. J. ALL CONSTRUCTION METHODS AND MATERIALS AND
�P A„ '� CHAMBERS IN BED FORMATION ADJUSTED GROUND WATER: NIA MAINTENANCE OF THE SEPTIC SYSTEM SHALL
; 1500 GAL D-BOX SEPTIC TANK PROVIDED: f500 GAL. MIN.
c OBSERVED GROUND WATER: NIA BOARDCONFOROFT HEALTH REGULATIONS.
5 AND LOCAL
SEPTIC TANK 6' CRUSHED S TON OR BOTTOM OF TEST HOLE l: 84,6 SOIL
oyl DESIGN RATESCS5 M/NINCH REQUIRED:COMPACTED BASE 4• ALL SEPTIC SYSTEM COMPONENTS LOCATED UNDER
y SOIL TEXTURAL CLASS - ,l
c
PROF I L C : NOT TO SCALE EFFLUENT L DAO l NG RATE - 0.74 GPD/SF AREAS SUBJECT TO VEHICULAR TRAFFIC OR GREATER
330 GPD / 0.74 GPD/SF - 446 S.F. REQUIRED THAN 3' IN DEPTH SHALL BE CAPABLE OF WITH-
STANDING H-20 WHEEL LOADS.
PlOV1DED: /0 HIGH CAPACITY INFILTRATOR
CHAMBERS. 62.5'x 7.79 SF/FT - 486 S.F. 5• ALL SEWER PIPE SHALL BE SCHEDULE 40 PVC D
LOCUS MAP APPROVED EQUAL.
486 S.F. x 0.74 - 360 GPD
PER TRANS. NO. X228042 DATED: 812212013
j 6. SEPTIC TANK AND D-BOX SHALL BE REINFORCED
PRECAST CONCRETE OR APPROVED POLYETHYLENE.
7-
SO I L TES T I J DA TAS BOTH SHALL BE WATERTIGHT, D-BOX SHALL BE WATER
HELL PER PLAIN INDICATES _ INDICATES TESTED FOR LEVEL WHEN THERE IS MORE THAN ONE
ON FILE AT M PERCOLATION - OBSERVED OUTLET.
HEALTH DEPT TEST GROUNDWATER
- - - 7. BEFORE CONSTRUCTION CALL "DIG-SAFE".
TP W/ P*14113 TP W2 I-688-DIG-SAFE AND THE LOCAL WATER DEPT.
F
NOR 1 ZON TEXTURE COLOR HOR/ZON TEXTURE COL 0R FOR L OCA T/ON OF UNDERGROUND UTILITIES.
TOWN WATER 0" 96, 1 0- 95.6
L OAM 10 YR Y 4 A
SAND 3/4 SAND 3/4 L OAMY IOYR
8 SEPTIC SYSTEM INSTALLER SHALL NOTIFY THE
DESIGN ENGINEER TWO DAYS PRIOR TO CONSTRUCTION
7" - - - - - - - - - - - - - - - - - - - - 95.5 8' - - - - - - - - - - - - - - - - - - - 94.9
B LOAMY l 0 YR 8 LOAMY IOYR OF THE SYSTEM TO ALLOW FOR SCHEDUL l NG OF THE
SAND 416 SAND 416 CONSTRUCTION INSPECTIONS.
24" - - - - - - - • - - - - - - - - - - - - 94. 1 24' - - - - - - 93.6
9. EXISTING SEPTIC SYSTEM TO BE PUMPED DRY AND
C I LOAMY MED IOYR C I LOAMY MED IOYR BACKFILLED.
O j") SAND AND 616 SAND AND 616
A S j� 1 52" GRAVEL GRAVEL
T � r A T l 1 LO10. INVERT AT THE DWEL L f NG TO BE RELOCATED TO THE
UN TA j V CATION AND ELEVATION SHOWN.
MD a - - - - - -
82` 89.3 �2' 88.8
C2 MED-COARSE IOYR C2 MED-COARSE IOYR
\ \ I SAND AND 518 SAND AND 5/8
GRAVEL GRAVEL
`N 82°-46'43-E \ 1 I \
I i
\ I
137.63 \ \\ \ t I\ NO WATER NO WATER
l20" 86. l 13,2" 84.6
P /3
EST BY STEPHEN HAAS
WITNESSED BY: DONNA M10RANDI
PERC RATE: l 2 MINIINCH
lb
\\ �"
\
Lu
TOWN WATER \ \\ EXISTING
\ { \ ^ SEPTIC TANK, 99.\11 \ \
4 \\ \\ \\ \\
\ \ \ \ \ \ TOWN WATER
,,ING
NG DD' K 'S€'PT I CI TANK \ \ \\ \ \
W511 10 1.0 OEO 1 0-0OJc� S -., p \\ \\
.yam { . .. Z` .•.•.'\i `, \ \\ \\ \
\ \ SM. COR�\lER STEP 1 °\ ::: ' '� 4.4
\ \ \\
y \ EL - 100\p
-59
I / ,t \ 10 NIGH CAPACITY \ 1 \
/ t )! { \INFILTRATOR'CHAMBERS \ \ \
EXIi ING
LEAN PIT I 1 94.3 1 \ \
rw
TOWN WATER
41
O ► 1 1 e \ \ -{{per
g'y, ,p� •d L:a
I { { { k4
t LOT 18 {I 16O 5653"W Zo13
I 3/ . 649+ S. F. 1 1 �0°
I I s ,
� I 1
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S EP T I C SYSTEM DES / ON
TONWWATER 44 MOUNTA / N ASH ROAD . MAP / 24 . PARCEL S 37
BARNS TABLE : ( MARS TONS M I L L S ) MA ,
WELL PER PLAN
ON FILE AT
HEALTH DEPT PREPARED FOR
LEGEND
■ CB CONCRETE BOUND T I MO T H Y M C L A U G H L ! N
-W WATER LINE O HYDRANT E SCAL : l - 20 St=P TEMBER / 6 . 2013
-G GAS L I NE
OHW- OVER HEAD WIRES
STEPHEN A HAAS
-0 LIGHT POST
�- ENGINEERING , I NC
UNDERGROUND EL ECTR 1 C L f NE
923 Route 6A
-T- UNDERGROUND TELEPHONE L l NE � � / ! I
Ya rrnc> u t hpo r t MA . 02675
• -CTV- UNDERGROUND CABLEVISION LINE
( 508 ) 362-8 1 32
+40,4 SPOT ELEVATION �l�i I
..•••40. EXISTING CONTOUR
{F01 PROPOSED CONTOUR
0 10 20 40 JOB NO., l 3-064
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4 N I&V G,4�C,. SEPT/C TA K
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