HomeMy WebLinkAbout0240 BOULDER ROAD - Health r Barnstable
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
a DEPARTMENT OF ENVIRONMENTAL PROTECTION
"':D
S 1 K
MAY 0 5 2005
TOWN OF BARNSTABLE
TITLE 5 HEALTH KEPT.
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM_ FORM
PART A
CERTIFICATION
Property Address: 240 Boulder Road
Barnstable MA 02630
Owner's Name: Roger&Vincentina Odoardi
Owner's Address: 76 Harley Street Apt. 1
Worcester MA 01606
Date of Inspection: April 18,2005 Job# 05-98
Name of Inspector: PATRICK M.O'CONNELL
Company Name: SEPTIC INSPECTION SERVICES CO.
Mailing Address: 189 CAMMETT ROAD
MARSTONS MILLS MA 02648
Telephone Number: 508-428-1779
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: 0N�F1ni
__X_ Passes �. •`s.9�'y'
Conditionally Passes AT I m
Needs Further Evaluation by the Local Approving Authority = ;
Fails
Inspector's Signature: Date: 4/18/05 es RTlF1 .�oQ'�•�`�
Fs INSPEG
The system inspector.shall submit a copy of this inspection report to the Approving Authority(Board of Heat 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: System in good condition,Leaching pit shows no evidence of hydraulic failure.
Recommend raising covers.
****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 1
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 240 Boulder Road,Barnstable
Owner: Roger&Vincentina Odoardi
Date of Inspection: April 18,2005
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
_XX_ 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:
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:
Titlo C inenantinn Fnrm Oil v,)nnn 2
Page 3 of I 1
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property YAddress: 240 Boulder Road Barnstable
Owner: Roger&Vincentina Odoardi
Date of Inspection: April 18,2005
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 public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(l)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
_ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier, if any)determines that the
system is functioning in a manner that protects the public health,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 a 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:
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r
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 240 Boulder Road,Barnstable
Owner: Roger&Vincentina Odoardi
Date of Inspection: April 18,2005
D. System Failure Criteria applicable to all systems:
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 ''/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.
_X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
_X_ Any portion of a cesspool or privy is within a Zone 1 of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
X_ 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 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.]
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:
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
the system is within 400 feet of 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 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.
Title C Tncnantin"Fnrm 411 C/IAAO 4
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 240 Boulder Road,Barnstable
Owner: Roger&Vincentina Odoardi
Date of Inspection: April 18,2005
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)on the site 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)]
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Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 240 Boulder Road,Barnstable
Owner: Roger&Vincentina Odoardi
Date of Inspection: April 18,2005
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: 0
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):
Seasonal use:(yes or no): Yes
Water meter readings, if available(last 2 years usage(gpd)): 2003—12,000 gal. 2004—21,000 gal.=45 gpd.
Sump pump(yes or no): No
Last date of occupancy: Occasional usage mostly in summer.
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
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: None
Source of information: Owner
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 a copy of the DEP approval
_Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Compliance date: 8/22/86
Were sewage odors detected when arriving at the site(yes or no): No
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Page 7 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 240 Boulder Road,Barnstable
Owner: Roger&Vincentina Odoardi
Date of Inspection: April 18,2005
BUILDING SEWER: XX (locate on site plan)
Depth below grade: 7'
Materials of construction:_cast iron _X_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: XX (locate on site plan)
Depth below grade: 6'
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:8.5' long x 5.2'wide—1000 gal.
Sludge depth: 0"
Distance from top of sludge to bottom of outlet tee or baffle: -
Scum thickness: 0"
Distance from top of scum to top of outlet tee or baffle: -
Distance from bottom of scum to bottom of outlet tee or baffle:-
How were dimensions determined: STICK WITH HINGE FLAP.
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
Baffles intact and clear,no sludLye or scum lavers due to low usaae Tank not in need of numpin¢at
this time.Recommend pumninQ every three years under normal use
GREASE TRAP: No (locate on site plan)
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.):
T;#1a C T"Onpotlnn Fnrm(/1;mnnn 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: 240 Boulder Road,Barnstable
Owner: Roger&Vincentina Odoardi '
Date of Inspection: April 18,2005
TIGHT or HOLDING TANK: No (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: IAlarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX:
XX (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.):
No solids or high stains,liquid level at bottom of outlet nine
PUMP CHAMBER: No (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.):
T;*1a i Tncna�tinn Fnrm Aii ci,)nnn 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: 240 Boulder Road,Barnstable
Owner: Roger&Vincentina Odoardi
Date of Inspection: April 18,2005
SOIL ABSORPTION SYSTEM(SAS): XX (locate on site plan,excavation not required)
If SAS not located explain why:
Type
_X leaching pits,number: One 6x6 pit.
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.): Pit shows no evidence of backup or surcharge
CESSPOOLS: No (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: No (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.):
Tirin i Tnonorfinn Rnrm Ail si,)nnn 9
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 240 Boulder Road,Barnstable
Owner: Roger&Vincentina Odoardi \
Date of Inspection: April 18,2005
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
Boulder Road
33 30
39
Water service
26
18
26
Garage
Tif1a.G incnarfinn Fnrm Aii c ,7nnn 10
Page I 1 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 240 Boulder Road, Barnstable
Owner: Roger&Vincentina Odoardi
Date of Inspection: April 18,2005
SITE EXAM
Slope None
Surface water None
Check cellar Dry
Shallow wells None
Estimated depth to ground water: More than 20 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:
_X_Observed site(abutting property/observation hole within 150 feet of SAS) .
Checked with local Board of Health-explain:
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Low point of abutting property is more than 20 feet lower than SAS.
T41. inonantinn Rnr 4/1 ci,)nnn 11
TOWN OF BARNSTABLE -�-
SEWAGE #'Th5fec-t pan
Vu!L,AGE —I �S b r ASSESSOR'S MAP & LOTS
IN 'S NAME&PHONE-NO.
SEPTIC TANK CAPACITY /aGb �wI
-1-RACHING FACILITY: (type) +` �' (size) 10 q
NO.OF BEDROOMS 3
BUILDER OR Q1 vCe.v1^I1AA
PERMITDATE: Ct3M CE 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
N
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R�fiy +.
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-,le:J C A,-'T ION SEWAGE PERMIT NO.
1,c-t- 14 '3oo ld e(A - S76
`wILLAGE z
INSTALLER'S NAME i ADDRESS
1
ell
��. B U I L D E R OR OWN ER
As„
DATE PERMIT ISSUED C, L-7Z96
0ATE. COMPLIANCE ISSUED z.� s�
30
le
y7
Fps
...........
THE COMMONWEALTH OF'MASSACHUSETTS
BOAR D , �FEALTH.. ..... . ..
.................OP.....-..- ...........................................
AppUratiou for Uhipoiial Works' Tongtrurtion ramit
Application is hereby made for a Permit to C nstruct or Repair Individual Sewage Disposal
Permit
to Repair I,.,
System at-
. .... ............ .....
................ ...................................... ...........e.Je..... .... ..... .................. .............................
Location-Address
4-oivoo................ ... .............................................................. .......
Owner Address
stalie Address
U
Type of Building
107 Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder
Other—Type of Building -----------................ No. of persons............................ Showers Cafeteria
Otherfixtures --------------------_---- ............................................................. ............... (T------------*------
Design Flow_______________________________ gallons per person per day. Total daily flow.........................................gallons.
9 Septic Tank—Liquid [09-gallons Length________________ Width._.__..----_.--- 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 Dosing tan
�X . ........... Date....Percolation Test Results Performed by....... .X"",
........... .......... ..... ..
Test Pit No. I----------------minutes per inch Depth of Test Pit---------___�._. -Lepth to ground wa�er---------- -----------
Test Pit No. 2................minutes per inch Depth of Test Pit.---_---..__--______ Depth to ground water----_--..-______-__.--_.
loo�
0 Description of Soil..................................................... ............. .............. ------------------ ........................
.................................................................. .. ... .................... .......... ... -—--•----------- -----------
U -. ..... —--- ----•-_--_------------------
--------------------------------------------------------------------------------------------------/---------------- ..............................................................................
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 THT-ILE, r 01 the State Sanitary Code—The undersi 504,rL rjjierrg3r not to place the system in
operatwil%until a Certificat of Compliance has been issued by rd of I ith.
44,&eL_ Signed.---. ... ....... ............ .... ........... ..... .............. ................................
-- ------- ----
ate
..............................r........................ .............../
Application Approved By.......
Date
Application Disapproved for the following reasons:................................................................................................................
.........................................................................................................................................................................................I---------------
Date
Permit No..... ............... .. Issued.......................................................
. . ..............
Date
No *._-5 a Fizz'.S6`...........
r
THE COMMONWEALTH OF MASSACHUSETTS
-- -- BOARD OF HEALTH
`^. -✓�.. .................OF........ ....
Appliratiun for Disposal 10orks Touutrurttun 11trutit
Application is hereby made for a Permit. to C nstruct ( or Repair, (-)- Individual Sewage Disposal
System at - / `� �'✓
r I�/
............... Cam:... - ....• ----- �i c G / c - ("
Location-Address
.............. j �.,--•�/ itL t, /'_"s" _Address
LO
t
_.�.._..... .._. .----...---' -'---'--- - ....... ............................................-........ .....
Owner
A
C/
nstalier, Address
UType of Building Size Lot............................Sq. feet
Dwelling1-4 No. of Bedrooms______________^�-'___.__________._.__— _Expansion Attic ( ) Garbage Grinder ( )
�`� Other—Type of Building ___ _________ No.'of° ersons___.._.__.__________________ Showers
YP g _____________ -..p ( ) — Cafeteria ( )
Design Flow_Other fixtures _gallons per ers
- ------ --•--
W g - g P P on per day. Total daily flow..______ ..............................gallons.
WSeptic Tank—Liquid'capacy --gallons Length................ Width................ Diameter________________ Depth................
Disposal Trench—No---------------__..... Width.................... Total Length............:....... Total leaching area--------------------sq. ft.
Seepage Pit No--------- Diameter__________________�Deptlh B�1� inlet___.. ,:._..._. Total leaching area...........___.._sq. ft.
� z Other Distribution box ( ) Dosing t
Percolation Test Results Performed by_______ _-._ Date ----- 1------
Test Pit No. I................minutes per inch Depth of Test Pit........... ._-.__. Depth to ground w ter_.____._'.._.__.__..___.
r3, Test Pit No. 2................minutes per inch Depth of Test Pit..................... Depth to ground water........................
Og------------------•-------•-•--------___------_______ ........................................................................
ofSoil......................... __'__------- -----------
-----...•--- --------------------•---------•'- ..........................................
cxj ---•-•-------•-•--••---•-••-•••••---••---•----•-•-'-•-••---'••-_. • V .. -••--------... -----------------------
-------------------------------------------•-------------'-'--'..-----------------------•---------�------- --------------------------------------------•--•-----------------------------___
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 11:: ;of the State Sanitary Code—The un(1 1 urtherag s not to place the system in. .
operat o� until a Certificate of Compliance has been issued b ~and of
f/ r'l
Signed -
Date /
Application Approved BY -> --=............................................. >...---_ /Dal,'�
Application Disapproved for the following reasons:............................................................................................................
. '--••---'•'---•-••----•••--------'-'--•----'---•...---•-•'•••-------•-•-•--••---------'••'---•-'-•'-'-"••---'-----'--'•"•••-•-•-'--•---••-•--•---------•-••••-••'----••--••-•'----•--••--•-----'-'--•-
- au
Permit No. Issued Date THE COMMONWEALTH OF,MASSACHUSETTS
BOARD OF-- - ALTH
`..................-OF....... ............................................
ttt Qlrrtifiratr of Toutpliaurr
THIS IS 0 ERTIFY, That the Individual Sewage Disposal System constructed or Repaired ( }
—~ '.._
by ...._... ...... ............ E. ................_.!..........................................
-----------•--,
InstallevOf
--------- --------••--•- ------:---
has been installed in accordance with the provisions of TITi-E j of The State Sanitary Cod as descr•bed in the .
application for Disposal Works Construction Permit No..c__ �-____ ____.__.. dated_---__ � ____________
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL ' ATISFACTORY.
� - 6'y�
DATE. .....--- ..................... Inspector.......................................-----••--•---•------------•------------------
THE COMMONWEALTH OF MASSACHUSETTS
✓� BOARD OF-'H' ALTH
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4 FE-E ................
Utspou Works,Tonu#rt ion rrutit
Permission is hereby granted.--•--- ••-•• !" I
....
to Construct ( ) or Repair ( )_.an Individu wage DispospLSystem
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Street
as shown on the application for Disposal Works Construction Permit N ._�__V_ Date P/.1.__7j -------------
Q Board of Health
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FORM 1255 HOBBS & WARREN, INC., PUBLISHERS
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LEGEND �35' _„•'" - .
EXISTING SPOT ELEVATION OxO A0. R'� CERTIFIED . PLOT PLAN;,;
EXISTING CONTOUR --- 0 - - - ✓T � ,_ ,
FINISHED SPOT ELEVATION ]
F�NISHED CONTOUR 0 i3I� &ovtYj�2 �'t�A ;
APPROVED , BOARD OF HEALTH 4,
.� `1. A ASS
DATE AGENT � SCAtrE�' `�- •+
JD DATE
LEVY & ELD.REDGE ASSOCIATES, INC.
CLIENT' S •:r,tMTIFY -THAT- THE PROPOSED .
!ENGINEERS-LANDSCAPE ARCHITECT8 JOB N0. �So 6UILDINO, SHOWN ON. THIS PLAN
!PLANNERS-LAND SURVEYORS
DR.BY� 2; CONFO,RMSRtsTO THE, ZONING LAWS
- — ' �• :'r:'., `'OF ';8 RNSTA®L :"MASS. «tii
712 MAIN STREET CH. BYE C P.
HYANN I S, MASS.
SHEET_L OF Z DATEf'� REG.—LAND SURVEYOR
rN.OTE /F E/TNER THE SEPT/C TANk OR r
/vo ,/T ARE MORE THAN /2**BEL0N/
/D pr. /N/N. (',-0�6,4
rRA OEM ,4 24"O/A M F7'4 Co V CR E'T:E COVER a
qF SJNALL B.E .0 P0UGNT TO 7RA0AE �-4N EXTRA
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O&/TLET SEPT/C -rA ,/,�.G//�T,
/IV,(ET DISTR/BE/j/ON sox FT. GRO[JND NI�ITER T.'IBLE
:SECTION oF•
Ol/TCETD/STR/,Bllp'/ON BOX /24L7 Fr. 5����E ��.SPQSA L SYS?'�M
INLET LEACH/NG PIT �„Q F'T.
L EACH/NG P/T T,q BULATlD/V
DESI6N CRITERIA $CALF %+" /=a" DIMEN-SION A
`� D/MENSlaN 8-��-FT.
M41MOER. OF BEDROOAf S• ' J D/MENS/ON C L_FT.
AI?6AGE0/SPOSAL [/NI7,_/Vox!� SO//- LOG
SO/L TEST
TOTAL E3T//►�L4TE0 FLO�i/ 30 GAL.�0.4Y SOIL TEST A/ SOIL TEST#2 /
N41148ER QF -,rACNl Va PITS _.. D �E"GEK �Z.�-0 ELEY. ,DATE OF SOI( TEST
S/DE LC`ACH/NG PER P/T SQ. RT. / RESULTS h//TNESSED BY ,�_Z_-b C N�
BOTTOM LE,ACN/NG PER P/T / T. ,
�SQ• F Z PC�'COLAT/ON RRTE#/ �-® M/ III NCN
TOTAL LEACH/1YG AREA '2SQ. F - AERCO[AT/ON/PATE2 MIN.�INCH
RESERVELEfECHJNGAREA_ ESQ. FT. ,T
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