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HomeMy WebLinkAbout0085 BRAGG'S LANE - Health .85 Bragg\sA jL�ane, " hu Commonwealth of Massachusetts -6a11 Title 5 Official Inspection FormI ,y.i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments _. � 85 BRAGG'S LANE Property Address '-- — r JILL ELMER p Owner --------------• ----- --- --- - Owner's Name information is required for every BARNSTABLE V1 MA 02630 5/21/2021 T ------_._..-— -- ...- —------------- ------ —�—.— page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: forms When fillingout f A. Inspector Information 51#r ISyb(p on the computer, use only the tab Trevor Kellett key to move your Name of Inspector — cursor-do not Ca e Cod Se tic Services use the return --�-- --- —p-c-------- ---------- -- ------ ---- - -- --- key. Company Name - 350 Main St. 4 Company Address _W_Y_armouth MA 02673 � City/Town------------- -- - State Zip Code r 508-775-2825 SI-13744 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address " listed above; the information reported below is true, accurate and complete as of the time of my - inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 5/25/2021 Inspector's Signature Date 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 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 form should be sent to the system owner and.copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t51nsp doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts !=-1 Title 5 Official Inspection Form -- I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 85 BRAGG_'S LANE Property Address -- JILL ELMER_ Owner Owner's Name Y --`-- information is BARNSTABLE - MA_ 02630 _ 5/21/2021 required for every _ __—____—_,- -.____ _ _— page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: - SYSTEM IS IN WORKING CONDITION 2) 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. Check the box for"yes", "no" or"not determined" (Y, N, ND) 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. ❑ Y ❑ N ❑ ND (Explain below): 15ins .doc•rev.7/26/2018 p Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection ®r , Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 85 BRAGG'S LANE _ Property Address --- JILL EL_MER Owner Owner's Name _- __---.-- ------.----_-_-- information is required for every BARNSTABLE MA__ 02630 - 5/21/2021 page. City/Town 'State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System,Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational, System-will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) 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. a. 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: t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form :-_ >� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 85 BRAGG'S LANE_ _ Property Address JILL ELMER_ Owner Owner's Name -------_— information is gARNSTABLE \ required for every MA 02630 5/21/2021 _ page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. 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 fecal coliform bacteria indicates absent 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. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No El ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool 15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts - ; ATitle 5 Official Inspection Form k . I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 85 BRAGG'S LANE Property Address — — -- JILL ELMER Owner Owner's Name information is BARNSTABLE _MA 02630 _ 5/21/2021 required for every _ . _ page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) 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 '/z day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply 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. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent 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 and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® 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. 5) 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. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section CA. 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 l5insp.doc•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection For _. -- i, Subsurface.Sewage Disposal System Form - Not for Voluntary Assessments 85 BRAGG'S LANE _ Property Address JILL.ELMER Owner Owner's Name information is BARNSTABLE MA 02630 5/21/2021 required for every A. - - - -------------------._...--- ------ ----- page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes" to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ® Have large volumes of water been introduced to the system recently or as part.of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? Z ❑ 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: ® ❑ Existing information. For example, a plan at the Board of Health. ® D 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(5)] t5insp.doc•rev 7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 °> Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 85 BRAGG'S LANE Property Address JILL ELMER Owner Owner's Name — — — information is gARNSTABLE _ required for every — _ _..__.. MA _ 02630 _ 5/21/2021 _ page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: 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 Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: - — Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage '20 - 107 GPD g ( Y g (9pd)) '19- 147 GPD Detail Sump pump? ® Yes ❑ No Last date of occupancy: CURRENT _ Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts a;._- Title 5 OffIcial Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 85 BR_AGG'S LANE__ _ ?_ Property Address JILL ELMER Owner Owner's Name _ --- — information is required for every BARNSTA_ BL_E _ _ _MA 02630 _ 5/21/2021 page. City/Town _ — — State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: ---- —.— Design flow (based on 310 CMR 15.203): Canons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: ---- — — Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: ---- — Last date of occupancy/use: Date - Other(describe below): 3. Pumping Records: Source of.information: N/A Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? ---- Reason for pumping: -.- .- 15insp.doc-rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Ins e6tio For 3�:� I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments _ ✓` 85 BRAGG'S LANE _ Property Address JILL ELMER -----------Nam-- ----- ------- ---------- --------Owner Owner's e information is /21 required for every BARNSTABLE MA 02630 5 /2021---- .....----- -- -- --------------..—..._.. --... --- ------ --- 21 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): Approximate age of all components, date installed (if known) and source of information: 1995 PER ASBUILT ON FILE AT BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer (locate on site plan): Depth below grade: 40" - feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): - - - Distance from private water supply well or suction line: 1 0'+- — feet Comments (on condition of joints, venting, evidence of leakage, etc.): LINE CHECKED WITH SEWER CAMERA AND WAS FOUND TO BE CLEAN AND PROPERLY PITCHED ------------ t5lnsp doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 "N Commonwealth of Massachusetts A, °TIT 5 Official Inspection For 1, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments A=t I.: `X` - '•` 85 BRAGG'S LANE___ Property Address — - JILL ELMER Owner Owner's Name information is BARNSTABLE MA 02630 5/21/2021 required for every ---- ---- - .._—..----=--------- ---...— ------- -- page. City/Town. State Zip Code Date of Inspection 0. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: 30" feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 GALLON Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle --5° -- 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 -- How were dimensions determined? I ESTIMATED Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1500 GALLON TANK IN GOOD CONDITION. PVC TEES IN PLACE AND CLEAN. TANK AT NORMAL OPERATING LEVEL. COVERS 10" BELOW GRADE ON RISER i5insp.doc-rev 7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts _ ;,; Title 5 Official Inspection Form I�,; . ;.! Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 85 BRAGG'S LANE Property Address — JIL_L ELM_ER _ Owner Owner's Name _ information is BARNSTABLE MA 02630 5/21/2021 ' required for every -------------..___...._.----.....--------------------._.._— ------ - - ------_ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene El 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: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank (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 per day t51nsp doc•rev 712612018 Title 5 Official Inspection Form,Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Tide 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 85 BRAGG'S LANE Property Address — JILL ELMER Owner Owner's Name information is required for every BARNSTABLE MA _ 02630 _ 5/21/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank (cont.) Alarm present: ❑ Yes ❑ No Alarm level: - -------- Alarm in working order: ❑ Yes ❑ No Date of last pumping: date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert EVEN 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 LEVEL AND WATERTIGHT 15insp dpc•rev 7/26/2018 Title 5 Official Inspection Form:.Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts Title 5 Off Ici l Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments -!' 85 BRAGG'S LANE Property Address JILL ELMER Owner Owner's Name ------- -- ------ ------.---- information is BARNSTABLE ....... —. -- —_,_--- page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 2-1000 GALPITS ❑ leaching chambers number: — — ❑ leaching galleries number: ' - ❑ leaching trenches number, length: - ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: --- -- ------- — l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts -- --= Title 5 0fflcil Inspection , Form Is Subsurface Sewage Disposal System Form - Not for Voluntary Assessments o . 85 BRAGG'S_LAN_E Property Address — — JILL ELMER Owner Owner's Name --- -- information is BARNSTABLE required for every - - -- - ----- ---- -- ------_--- - -- - MA--- 02630 5/21/2021 _ page. City/Town State Zip Code Date of Inspection D. System Information (cant.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 2-1000 GALLON PITS FOUND IN OPERATING DURING INSPECTION WITH NO EVIDENT STAINING. --- -- f ---- - ---- - 12. Cesspools (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 ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 15insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage •Disposal System Page 14 of 18 P Y 9 Commonwealth of Massachusetts A, } Title 5 Official Inspection Form l=d.1'`i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 85 BRAGG'S LANE Property Address —`---� --- — JILL_ELME_R Owner Owner's Name—�-- -- -------.---- -- ------ information is BARNSTABLE MA 02630 5/21/2021 requiredfor every -----.__-------..._.__—_------------_---------------- - ---------- ----._--------- page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: - - --- Dimensions — ----- -.— Depth of solids ---—.._—....- -- --- ------ --- Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts gifts Official ial Inspection For' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4.7 85 BRAGG'S LANE Property Address - JILL ELMER -- _ .__...---_ ---------_ — -------- ..-- ---_....... Owner ----- ---- ------ Owner's Name information is BARNSTABLE required for every __._......... -- ......._..— ----..........-----......_..—.__._......--------- MA.._.._.- 02630 -- _ 5/21/2021 page. City/Town State Zip Code Date of Inspection T D. Systern Information (cont.) s 14. Sketch of Sewage Disposal System: Provide a view 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. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately 1 i i 6�•� ..-..'��i'.W;�'ak�M...ruwaau.-xwnsa2cn'iroiK��-'^.+13u1 ,,,��--�" ' I i 15insp.doc•rev 712612018 T;:e 5 Off c.al i^spect,cn Fcrm-Subsurface Sewage Disposal System-Page 16 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection For i7) Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 85 BRAGG'S LANE --—..-------------- --._- --------- ---. _......-------------- Property Address JILL ELMER _ Owner Owner's Name ,--- information is BARNSTABLE required for every. MA 02630 _ 5/21/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: +12'_-_ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record- If checked, date of design plan reviewed: Date —� ❑ 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: NO WATER ENCOUNTERED 4' BELOW SAS Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev,7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts `title 5 Official Inspection Form jj F�Iji •t sl Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 85 BRAGG'S LANE . Property Address ----- ----...._.—__ ------------- -- - JILL ELMER Owner Owner's Name information is BARNSTABLE MA 02630 5/21/2021 required for every --------- ---------------------------._._.... ___---..__ ----------- -- ---- page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. y Z B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ' ® D. System Information: For 8: Tight/Holding Tank— Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 J E. ' ICKEY rwa& K. jrW1. f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION{ FORM , CERTIFICATION Name of Inspector: Donald Perkins Company Name: Hickey Construction Company, Inc. Company Address: 38 Rosary Lane, Hyannis, MA 02601 tel : (508) 771-4128 Property address: %S `?tee^LL..S %..A Cert_x,fz_c t_:i.;.o.n....._ _ _a..tern.ent_ I certify that I have personally inspected the sewage disposal system at 'this address and that the information reported is true, ;:accurate and complete as of the time of inspection. The inspection was performed and any recommendations regarding upgrade, maintenance, and repair are consistent with my training and experience in the proper function and maintenance of on--site sewage disposal systems. Check One: -� I have not found any information which indicates that 'the system fails to adequately protect public health or the environment as defined in 310 CMR 15. 303. Any failure criteria not evaluated are stated in the FAILURE CRITERIA section of this form. I have determined that the system fails as defined in 310 CMR 15. 303. The basis for this determination is provided in the FAILURE CRITERIA section of 'this form. Inspector' s signature: Date : Original to system owner: S eN,27— Copies to: Buyer (if applicable) � - approving 'authority 38 Rosary Lane • Hyannis, MA 02601 508-771 -4128 7' SUBSURFACE W BE AGE DIBP08AL SYSTEM INBPECTION FORM -, Address of property ar `3a_AC_C S � �� 34-�►t �� �s owner' s name UAt� '. Date of Inspection PART A CHECKLIST Check ' - the following have been done: Pumping information was requested of th� occupant, and Board of t alth. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the sy em recently or as part of this inspection. As built plans have been obtained and examined. Note if tYe' y are not available with N/A. The- facility or dwelling was inspected for si ns of sewage 9 g back-up. _.. 4 j� /The site was inspected for signs of breakout. All system .components, excludingthe SAS, have been located on the site. 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. The size and`- location of the SAS on the site has been determined based o existing information or approximated by non-intrusive methods. The facility owner (and occupants, if different from owner) were provided with information on the proper maintenar�.ce of SSDS. AP � v�i ems' • �UQ 4 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION FLOW CONDITIONS If residential , number of bedrooms number of current resident garbage grinder, yes or no laundry connected to s _ em yes r no seasonal use, yes o no If nonresidential, calculated flow: water meter readings, if available: Last . date of occupancy GENERAL INFORMATION Pumping records and source of(,information: System pum s ' of inspectio yet r no if volume pum eason for pumping: Ty of system Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Other (explain) Approximate age of all components. Date installed, if known. Source of information: 'C3 c,i�ASS Sewage odors detected when arriving at the site, yes 'J 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SEPTIC TANK: (locate on site plan) depth below grade: material of construction: oncrete metal FRP other(explain) dimensions: (, sludge depth distance from top of sludge to bottom of: outlet tee or baffle 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 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, recommendations for repairs, etc. ) DISTRIBUTION BOX: (locate on site plan) l , L� , depth of liquid level above outlet invert Comments: (note if level and ...distribut.ion is` equal,- evidence of solids. carryover, evidence of leakage into or out of box, recommendation for repairs, etc. ) PUMP CHAMBER: (locate on site plan) pumps in working order, yes or no Comments: (note condition of pump chamber, condition of pumps and appurtenances recommendations for maintenance or repairs, etc. ) i 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SOIL ABSORPTION SYSTEM (SAS) : (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) , If not determined to be present, explain: T eaching pits and number er eac leaching galleries an n-uxmber leaching trenches, number, length leaching fields, number, dimensions overflow cesspool , number Comments: (note condition of soil , signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or. repairs, etc. ) CESSPOOLS (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 (cesspool must be pumped as part of inspection) Comments:. (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,etc. ) PRIVY: (locate on site plan) materials of construction dimensions depth of solids Comments: (note condition of soil , signs of hydraulic failure, level of ponding, - condition of vegetation, recommendations' for maintenance or repairs,etc. ) 4 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE L=SPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100 ' a DEPTH TO GROUNDWATER depth to groundwater method of determination or approximation: . 12 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C FAILURE CRITERIA. Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of determination in all instances. If "not determined" , explain why not) Backup of sewage into facility? Discharge or ponding of effluent to the surface of the ground or surface waters? VO Static liquid level in the distribution box above outlet invert? Liquid depth in cesspool <6" below invert or available volume< 1/2 day flow? Required pumping .4 times or more in the last year? number of times pumped Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? Is any portion of the SAS, cesspool or privy: below .the high groundwater elevation? within 50 feet of a surface water? within 100- feet of a surface water supply or pp y tributary to a surface water supply? within a Zone I of a public well? within 50 feet of a bordering vegetated wetland or salt marsh (cesspools and privies only, not the SAS) ? within 50 feet of a private water supply well? ;. " 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. r TOWN OF'BARNSTABLE �. LOCATION 97 �j^ (/ � � SEWAGE # VILLAGE S y Jtq fa !1 le ASSESSOR'S MAP & LOT ' INSTALLER'S NAME & PHONE NO. C. C A ,e SEPTIC TANK CAPACITY`? 0 LEACHING FACILITY:(type) l f a (size) . NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER OR OWNER r`,O- ij DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED VARIANCE GRANTED: Yes No j` r w ©� cm L t �oYuis �...� T11E COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE r^ Appliration for MoVasal Works Tonstrurtiun Prrmit Application is hereby made for a Permit to Construct ( ) or Repair (0) an Individual Sewage Disposal System at: Location-Address or Lot No. ............................................... ----------7------------------------------------------•----------•-----------•-------------------- wner Address W t�lC a �:� rwI .........:.. ................................. Q ................... �- -- F 6A_^12 .................................... Installer Address Type of Building Size Lot...............0.......-----Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building . No. of persons._----_-_-__•-_•----___-___- Showers — Cafeteria Q' Other, fixtures ---------------------------------------------- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth-----__-_---__-- x Disposal Trench—No..................... Width.................... Total.Length.................... Total leaching area....................sq. ft. > Seepage Pit No----------_--_--- Diameter.................... Depth below inlet............0....... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.. Date -------------------- ,� Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ fT Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground Water......................... a •-------•--•--•-••-------•-----------•--------------------••---•....------------......-----••----••.....•......................-............................. 0 Description of Soil......................................................-.................................................................................................---............. x w U Nature of Repairs or Alterations—Answer when applicable.._._ ____qA ._..._..(i- 0...... j._.. . -- "'Q s Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed ...... :... ----- ; .......a 7 SJ ---------------- Application Approved BY .... .............. ...' ----.................... ........................................ Dace Application Disapproved for the following reaso T: ------------------------------------------------------------------------------------------------------------------------------------ ---- ---------------------------------- ---- --------- . ------------------------........------------------------..... .... ---- --- -----------------------...... Permit No. -�J.-- --. .. ------------ Issued ....D�e .. - Fxs. , �..........-- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE App iration for Uiipnsal Works Tonstrur#ion Prrutit Application is hereby made for a Permit to Construct ( ) or Repair (?0) an Individual Sewage Disposal System at: ................1 8..... ................... rtvz,N S Location-Address or Lot No. ............................................... ...........-...................................................................................... Owner `" Address W 1�kC �LCZt �Q1J 1 ice' � +'MIC�t ! [^' C��Q�K/Cs a ............••.. -- ................................................... Installer Address d Type of Building Size Lot----------------------------Sq. feet U Dwelling—No. of Bedrooms................................ .....Expansion Attic ( ) Garbage Grinder ( )U a Other—T e of Building No. of persons............................ Showers — Cafeteria al Other fixtures -------------------------------------------•-- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................ W 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 tank ( ) HI Percolation Test Results Performed bY.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ (% Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 --•------------•------••-•--•--••-••-••-•-••-•••-•••••••••....-•--••-•-----•••--•-•-•----------••-•-......................................................... 0 Description of Soil------------------------------------------------------------------------------------------------------------------------------------------------------................ W U ----------------------- --------- ----------------------------- --------------------------------- ----------------------- ------------------------------------------------------------- -•-------- W U Nature of Repairs or Alterations—Answer when applicable....kKft----------0'Q;5�.......�;s 0_0.......C!A 4co!�_____J-E� ......................... .............................. ^� --------f !( fhc.o(/w Q---------�--------- tA7-^ .r!...------._Vn T j_ --- � Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed ------ G-" --= ------------------ ----------- ......1...7.. ... - ApplicationApproved BY ... --------� V - -------------------- ................................ Dale Application Disapproved for the following reaso -------------------------------------------------------------------------------- --------- � / Dace Permit No. ......�/ �........ Issued f /Z --- ------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE (�er#ifiratr d C antylian e THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (� ) by......T Et(X ......... j s ----------------------------------------------------------------- ........................................................ Installer at ...... S '1-4J-r->...---yLx..-J= -...........I...--..1.�....-1±-.N S�i.v'3LC has been installed in accordance with the provisions of TITLE 5 The State Environmental Code as described in the application for Disposal Works Construction Permit No. ... pp�� NEAS ..... dated ................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE ICONST A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE - .. .................. Insp ctor .... .. Q o04 THE COMMONWEALTH OF MASSACHUSETTS ? BOARD OF HEALTH G� TOWN OF BARNSTABLE No....11.. ............. FaE............... .... Disposal Vorks Tunstrnrtion "pantit Permission is hereby granted.•---�`-«�........t b ...•.......•.............................................•---•- to Construct ( ) or Repair ( an Individual Sewage Disposal System .. Street as shown on the appli tion for Disposal Works Constructio �P-crmit No � �. 1. .... ..��....... )oalT .. !. . I�.. (/J /...............•---............. ; of eal 3 DATE 1!l I FORM 36508 HOBBS&WARREN.INC..PUBLISHERS z i 4/22/2021 ShowAsbuilt(1700X2800) TOWN OF B'ARNSTABLE LOCATION //q/ r ZGu G SEWAGE 0 95 2 VILLAGE Gee 2�9-6 4 y kS�a ASSESSOR'S MAP 6 LOT @ISTALLER'S NAME 6 PHONE NO. [ r'A ,SEPTIC TANK CAPACITY LEACHING FACILITY:(tnm) C /00o I Q (size) Sr NO.OFBEDROOMS� PRIVATE WELL OR PUBLIC WATER_ S Y OR OWNER 07 5' e-itl4 C DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED.•_S�I� VARIANCE GRANTED: Yes No I C15-67.4 I� https://itsgldb.town.barnstable.ma.us:8431/Home/ShowAsbuilt?mp=299043004&sq=1 1/1 CA cp -4 o n+ rn _ 1c a 'o 310 = Ln 30 �. 3 r" 2 ZY 3 ® o v r" (1„ �s 74 • � z q C ss w eticev� � �- i o0 r N J r c q u Fps..`--?/' .. P �•v ? Y -�-1a I THE COMMONWEALTH OF MASSACHUSETTS ,y BOARD OF HEALTH ............ ...................------..OF...........:...........................----------------------------............._........ a Appliration for DhiposFai Works Tonstrnrtion ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal SAE .......................................................... ------------'-"'-'-- ------------------------------------------ �.---C-- Location-Address or Lot No. ...... " -c. LT................................... Address Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms........ ..........................Expansion Attic ( ) Garbage Grinder ( � aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria/ ) P4 Other fixtures -----•......'--•--•-'---------•. . W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity. .gallon Length................ Width................ Diameter................ Depth................ x Disposal Trench—No._.lDP2..�SAWWe4q_— otal Length__.................. Total,leaching area....................sq. ft. Seepage Pit No--------------------- Di eter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( m Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.........._............. •---•-•-'--------------------------------------•'--------------..................._......•'-•................................................................ O Description of Soil...... . U '--.....--'-'-'•'................'---••-'••---'--'--•-•-'-'---'-'._.........-'--_._..._ ----••--'--""...... Z --'--••---------------------••----...•--'--'--•--•-•-----•---------------------------••'-•--"---'-'....'•"---'--------------------'-'-•-----------••-'••••-"--••-'•--•-••-•----••"----'--'-•-.'-'''- UNature of Repairs or Alterations—Answer when applicable......................................................................................... ---------------------------'--------------------------------------••-•-"-•'-'----'-.......-••--••••'.........'--'-•"--'-••-'-•-••-"'-••--'-'-•--•.•................................................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iIThh. 5 of the State Sanitary Code—Tye undersigned further agrees no lac he/-a s e�— operation until a Certificate of Compliance has bee sued b the board ealth' 4 1 r.--• .................. .......................... Date Application Approved By................. =.....l-v�"--- ••. . ------••---- � ... Date Application Disapproved for the following reasons-.........................-..................................................................................... .......................................------------------•---•-----.....----'-------•--.....----'----------•-•--••••--••-••----•••----•-•'--•---••-----••---•-'••--'-"-'--••......--••-•-"--.....---- Date PermitNo......................................................... Issued-....................................................... Date 4 ............................. ........... THE COMMONWEALTH OF,MASSACHUSETTS Ig" BOARD OF HEALTH .................. ------ .................OF Aliptiration fax Dispaiial Works Tomitrurtion Fautif Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal 4ystekn at: 4.(V .......................................................... .................................................a................................................ L !s or Lot No. ............. .................................... ................................................................................................. camm Address .......... ........ Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms....... ..................................Expansion Attic Garbage Grinder Other—Type of Building ............................ No. of persons............................ Showers Cafeterie'( Otherfixtures ........................................................................................................................................................ ,Design Flow.............................................gallons per person per day. Total daily flow............................................gallons. 1:4 Septic Tank—Liquid capacit �`Tallons Length________________ Width___.__._._______ Diameter-___--________ - Depth______.__.__._.. Disposal Trench—No. ln�? t V_i��i _2 Length____________________ Total.leaching area....................sq. ft. Seepage Pit.No--------------------- Diameter.___..___._...____._ Depth below inlet._._.___.____._..... Total leaching area..................sq. ft. Z Other`Distribution box �,/) Dosing tank ( ) Percolation Test Results Performed by---...................................................................... Date............... ------------------------- Test Pit No. I................minutesperinch Depth of Test Pit_._________________. Depth to ground water_.___._..________._____. rXq Test Pit No. 2................minutes per inch Depth of Test Pit____._.__.__.___..._ Depth to ground water..____.____.___._.___... 9 ............................................................................................................................................................. 0 Description of Soil.......'� -------------------------------------------------------------------------------------------------------------------------------------------------- ...................................................................................................................................................................................................... U W ........................................................................................................................................................................................................ �4 U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ........................................................................................................................................................................................................ Agreement- The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 4 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until-a.-Certificafe of Compliance has beelLissue d bthy the board o0health s9 ------------ --------- ........ ................ Si rl�� D to Aate Application Approved By...................... .............. ....... Application Disapproved for the following.reasons:................................................;............................................................... .............................................................................77,--------------------------------------;...................................................................................... Date PermitNo......................................................... Issued.................................. ....................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... Tntifiratr of Tamptiatta THIS IS TO CERTIFY, That the Individual Sewage Disposal System. constructed or Repaired by.............. .......................................................­............................0......................................................................... Installer at............................................ ..................................................................... has been installed in accord�ihce with the provisions of TUZ� 50 he State SanitaryCode al, descrih.1,4n the —2 4�� application for Disposal Works Construction Permit No...............------ ......... dated-------------- ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DAT ............:3L P*6............................................. Inspector............. . E .....................7 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .....................................OF............................................................. ............ .............. Permission is hereby granted....___(00410".................................................................................................................. to Construct ( X') 9r\Repair an Individual Sewag�Qlsposal System at No........"I........i.:.?, nl��.......2r., - ........................................................................................... Street as shown on the application for Disposal Works Construction Perm ............ Dated...... - --------- ...*......... ......................... ...... m........................................... Board of Health DATE.......... ......................................... FORM 1255 A. M. SULKIN, INC., BOSTON / 30• s . 0 — I � / 6T - i S 77'�} 10 1 �a V ��fi G° Gp, b?�sT�n/G 48 f 37'� Sys ¢ ti CERTIFIED PLOT PLAN LOCATION 4a,19ec' e4 ,2ev�ser i��z/B6 SCALE . /..'.:-.!,Q. DATE PLAN REFERENCE.-4.4'/�i�.. ' �,�U} t�+C9. ci;iti�i• f.,:�i1S° EXIST//YG-' /3U/L�//1/G' I CERTIFY THAT THE z lAVf�e .Co vsyfA/47"!0�V SHOWN ON THIS PLAN IS LOCATED ON THE GROUND AS SHOWN HEREON AND THAT IT CONFORMS TO THE SETBACK REQUIREMENTS OF THE TOWN OF /?9!9.WHEN CONSTRUCTED. DATE J j LT REGISTERED LAND SURVEY04 ,q EL TOP OF FOUNDATION rrlcr,, Lw�.c.�awG — CONCRETE COVER • CONCRETE COVERS ' 4"CAST IRON � ' I2 MAX. 12 MAX OR SCHEDULE 40 4"SCHEDULE 40 PVC (ONLY) PVC PIPE PIPE - MIN. • PITCH 1/4"PER FT LEACHPITCH I/4 PER.FT - PIT PRECAST INVERT J LEACH INO e EL..�7-={6 \- w Z., PIT OR INVERT INVERT INVERT SEPTIC TANK EL. `�l• '�% 910SX' EL�^Y•. , >_ EQUIV ``��" GAL . INVERT_ " 3/4' TO I I/2 e; EL `��-�`^.- q/ 1 Z_ INVERT w W . t EL.. EL.-4— r . ' I u-o c•. 1 WASHED W STONE I z PROFI LE OF GROUND WATER TABLE SEWAGE DISPOSAL SYSTEM NO SCALE 1 ! SOIL LOG WITNESSED BY ' DATE xT..Z Z//'� T I M E e- . . . F� . BOARD OF HEALTH TEST HOLE I TEST HOLE 2 f%Ist+v�c Coni�lt j ENGINEER ELEV .1 7�, ELEV. -'`�'. DESIGN DATA NUMBER OF BEDROOMS 3 GZ 43,-7a TOTAL ESTIMATED FLOW . . .. . GALLONS/DAY BOTTOM LEACHING AREA //'�'/. SO.FT. /PIT/ v , S Are� SIDE LEACHING AREA 2..��• � SQ.FT./ PIT//QF ' GARBAGE DISPOSAL ` . (50 % AREA INCREASE) TOTAL LEACHING AREA - �1:. SQ.FT PERCOLATION RATE Tfl MIN/INCH WATER ENCOUNTERED LEACHING AREA PER PERCOLATION RATE � �. SQ.FT/4 P NUMBER OF LEACHING PITS 4P.-YC P/ APPROVED BOARD OF HEALTH ' `� S dr � .-. . DATE AGENT OR INSPECTOR \�p�S6 OF f+�s Q , ,So . v A t � 1 i PETITIONER r .. 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