HomeMy WebLinkAbout0117 COBBLE STONE ROAD - Health 117 Cobble Stone Road,
'A 316-046 Barnstable
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LOCATION:
VILLAGE•
L'6'I # PERMIT
INSTALLER' S NAME: T fun)
INSTALLER' S PHONE # : '36�—C
LEACHING FACILITY: (type)
NO. OF BEDROOMS: f
BUILDER OR OWNER:
PERMIT DATE
COMPLIANCE DATE
DRAW DIAGRAM ON BACK
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LOt'ATION 112 40M�a&g SEWAGE #
VILLAGE ASSESSOR'S MAP & LOT-3 1(t G��
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY A
LEACHING FACILITY: (type) �� (size) /oBd
NO.OF BEDROOMS
BUILDER OR OWNER �/DV !� 1,6
PERMITDATE: /"' l COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and 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 F cility(If any wetlands exist
within 300 fe of leac ' g ili Feet
Furnished
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COMMONWEALTH OF MASSACHUSETTS
ID EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET. BOSTON, MA 02108 617.292.5500 9 d0
WILLIANI F.WELD RECEIVED TRL XE
Govcmor J U L 15 1997
ARGEO PAUL CELLUCCI DA`CD B 'HS
Li.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM TOWN OFBARNSTABLE Co oncr
PART A
HEALTH DEPT,
,� •,`,
CERTIFICATION
Property Addressil 7 Cobblest-one -}r--,Barnstable Address of Owner: $
Date of Inspection: 7 (If different)
Name of Inspector: 2`014 13h P. Macomber Jr.
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15,000)
Company Name: Joseph P. Macomber & Son Tnc .
Mailing Address: Box 66, Centerville , M 2-0066
Telephone Number: — — 338
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reponed 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:
Passes
Conditionally Passes
Needs Funher Evaluation By the Local Approving Authority
_ Fails
Inspector's Signature: �,� Date:
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (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 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:
have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
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.
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 04/25/97) Page 1 of 10
DEP on the World Wide Web: http:llwww.magnet.state.ma.u side p
Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 1 1 7 Cobblestone Drive, Barnstable, Ma. 02630
Owner: Phyllis Melehionna
Date of Inspection: 7/1 /9 7
B) SYSTEM CONDITIONALLY PASSES (continued)
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a 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 levelled 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:
1W 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:
j Cesspool or privy is within 50 feet of a surface water
�1 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 PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
A The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or
tributary to a surface water supply.
The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS 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 presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method used to determine distance (approximation not valid).
3) OTHER
(revised 04/25/97) Page 2 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 1 7 Cobblestone
� to e Drive, Barnstable, Ma. 02630
Owner: Phyllis Melehionna
Date of Inspection: 7/1 /9 7
D) SYSTEM FAILS:
You must indicate ei;•.er "Yes" or "No" as to each of the following:
1 have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303 The bans
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Yes No
Backup of sewage into 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 clogged SAS or
cesspool.
Static liquid level in t e istribution box above outlet invert due to an overloaded or clogged SAS or cesspool
2 AT
Liquid depth in Eesspaai 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)
Number 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 I 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 above:
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
/Ow 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 11 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 04/25/97) Page 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: )17 Cobblestone Drive, Barnstable, Ma. 02630
Owner:
Date r: Inspection: Phyllis Melehionna
7/1 /97
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
Pumping information was provided by the owner, occupant, or Board of Health.
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 system recentiv or
as part of this inspection.
As built plans have been obtained and examined. Note if they are not available with N/A.
_ The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
The site was inspected for signs of breakout.
_ All system components, ruding the Soil Absorption System, 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 Soil Absorption System on the site has been determined based on:
The facility owner (and occupants, if djfferent from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal System.
Existing information. Ex. Plan at B.O.H.
_ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) (15.302(3)(b))
(revised 04/35/97) P&ge 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: j 1 7 Cobblestone Drive, Barnstable, Ma. 02630
Owner: Phyllis Melehionna
Date of Inspection: 7/1 /9 7
FLOW CONDITIONS
RESIDENTIAL:
Design flow. ;?06 ?.p-J` droom for S.A.S.
Number of bedrooms:
Number of current residents o�
Garbage grinder (yes or no).jE_✓ pp
Laundry connected to system (yes or no):*'7
Seasonal use (yes or no)v06 r- j(?
Water meter readings, if available (last two (2) year usage (gpd): � S_:7 A
i� Sump Pump (yes or no):
_P_12� '4VJ
Last date of occupancy.
COMMERCIAUINDUSTRIAL:
Type of establish m nt: /)Ip�
Design flow: gallons/day
Grease trap present. (yes or no)zz?�
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: Ald
Last date of occupancy:
OTHER: lDescribe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and sourcg f inf r ation:
System pumped as pan of inspe ion: (yes or no)
If yes, volume pumped: Rall }> ) f D
Reason for pumping
TYPE•OFF STEM
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)
I/A Technology etc. Copy of up to date contractl
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information:
Sewage odors detected when arriving at the site: (yes or no),ev_a
(revised 04/15/97) Page 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: Cobblestone Drive Barnstable Ma. 02630
i
17 Cobb , ,
Owner:
Date of Inspection: Phyllis Melehionna
7/1 /97
BUILDING SEWER:
(Locate on site plan)
Depth below grade:
Material of construction: _ cast iron /40 PVC _ other (explain)
Distance from private water supply well or suction line U9
Diameter �_
Comments: (condition f oints, vents evidence of leakage, etc.)
�uvrS ) �re �r. .tla - !4- �' o .L4.C4e Sys; .► �S 1�.r�T t��v��s� r�r
n g e 'U(PA) --
SEPTIC TANK:,6Qk3iri"A$
(locate on site plan)
Depth below grader
material of construction: concrete _metal _Fiberglass _Polyethylene —other(explain)
If tank is metal, list age&A Is age confirmed by Certificate of Compliance _(Yes/No)
Dimensions: F��
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: 0
Distance from bottom of scum to bottom of outlet tee or affle:�
How dimensions were determined:
Comments:
(recommendation for pumping, conditi n of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage etc.)
44
E
GREASE TRAP:
(locate on site plan)
Depth below grade:%
Material of con struaion:t/�concreteN�lmetal fiberglass4,�tPol yet hylene4/4other(explain)
Dimensions:_ 4,W
Scum thickness:Z2A
Distance from top of scum to top of outlet tee or baffle:_,VA
Distance from bottom of scum to bottom of outlet tee or baffle:-,4
Date of last pumping:
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.) 0,6&& ?Sy T i9Y Id stl�J' ,Q/Y4�.rJT
(revised 04/35/97) Page 6 of 10
J
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:11 7 Cobblestone Drive, Barnstable, Ma. 02630
Owner: Phyllis Melehionna
Date of Inspection?/1 /97
TIGHT OR HOLDING TANK:�eiTank must be pumped prior to, or at time, of inspection)
(locate on site plan)
Depth below grade:
Material of construction:Ito— oncretelgmetalj�*iberglass4/*Polyethylene.,Qother(explain)
Dimensions: A4
Capacity: 4)A gallons
Design flow: >r� gallons/day
Alarm level: 1VW Alarm in working order _ Yes; _ No
Date of previous pumping: A11L_
Comments.
(condition f inlet tee, con tion f alarm and float switches, etc.)
T.P, 5 i9�^G .U�17` reS�v T
DISTRIBUTION BOXJ-- �
(locate on site plan)
Depth of liquid level above outlet invert: A49
Comments:(note if le v I an istribu ion is equal, eviden e of solids carryover, evidence f leakage into or out of box, etc.) AQ-1JBA? /S
AP-
C3'
PUMP CHAMBERA/h4'K1_
(locate on site plan)
Pumps in working order: (Yes or No)—&z
Alarms in working order (Yes or No)—,to
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 04/25/97) Page 7 of 10
it
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
l
Property Address: 117 Cobblestone Drive, Barnstable, Ma. 02630
Owner: Phyllis Melehionna
Date of Inspection: 7 1 97
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:
Type: 1
leaching pits, number:_
leaching chambers, number:
leaching galleries, number:
leaching trenches, number,length: O
leaching fields, number, dimensions:
overflow cesspool, number:
Alternative system: A/ �d
Name of Technology: ��!
Comments:
(note con ition of soil, signs of hydraulic failure, level of pondinp, condi ion of vegetation, etc.)
a
CESSPOOLS:
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert: ,f/R
Depth of solids layer: �1/A
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, etc.)
s s
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.)
(revised 04/25/97) Page 8 of 10
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEA INFORMATION (continued)
Propeny Address: J1 7 Cobblestone Drive, Barnstable, Ma. 02630
Owner: Phyllis Melehionna
Date of inspection: 7/1 /9 7
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references hndmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
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Pago 9 of 10
H7 Cobble 51-on�
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 17 Cobblestone Drive, Barnstable, Ma. 02630
o,,+ner: Phyllis Melehionna
Date of Inspection: 7/1 /9 7
Depth to Groundwaterc Feet
Pleases indicate all the methods used to determine High Groundwater Elevation:
C/ Obtained from Design Plans on record
Observation of Site (Abutting property, observation hole, basement sump etc.)
�etermrne it from local conditions
Check with local Board of health
Check FEMA Maps
heck pumping records
Check local excavators, installers
Use USGS Data
Describe in your own words ho�jyou established the High Groundwater Elevation. (Must be completed)
ev-
(revised 04/25/97) Page 10 of 10
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'I.OWN OF Barnstable WARD OF HEALTH �
SUHSUUACF SEWAGE D1SfOSAL SYSTEM INSI'FCTION FORM - PART D - CFwrIFICATIO.N
—TYPL OR PRINT CI.EARLY—
PROPERTY INSPECTED
STREET ADDRCSS17 Cobblestone Drive, Barnstable, Ma. 02630
ASSESSORS MAP , BLOCK AND PARCEL #
OWNER ' s NAME PhylliseMelehionna
PART D - CERTIFICATION I
NAME OF INSPECTOR Joseph P . Macomber Jr .
COMPANY NAME Joseph P. Macomber y ion , Inc .
COMPANY ADDRESS Box 66 Centerville , Ma. 02632-0066
S t r 0 Q t Tovn or City gtat, t,p
COMPANY TELEPHONE (508 ) 775 -3338 FAX ( 508 ) 790 -1578
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system n �
this address and that the information reported is true , accurate , and
complete as of the time of .inspection . The inspection was performed and anv
recolnlnendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance o site sewage disposal systems ,
Check one :
System PASSED
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
healLh or Lhe environment as defined in 310 CMR 15 - 303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section o
this form ,
System FAILED* \
The inspection which I have con acted has found that the system fails to
pro LecL the public health and the environment in accordance with Title
5 , 310 CMR 15 , 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
Z I"
inspector Signature i Date �-
r;ne copy of this certification must be provided to the OWNER, the BUYER
( Where applStable ) and the BOARD OF 112AL'1'll ,
• I ! the inspection FAILED , the owner orsoperator shall upgrada the ayate7
it.hin one year of the dote of the inspection , unless allowed or require .
otherwise as provided in 310 CFIR 16 , 305 ,
partd . dcc
f<
�G
W I
THE COMMONWEALTH OF MASSACHUSETTS
DEPARTMENT OF E ONMENTAL PROTECTION
r
BE IT KNOWN THAT
Joseph P. Macomber, Jr.
Has satisfied the Department's qualifications as required and is hereby
authorized to use the title
CERTIFIED TITLE 5 SYSTEM INSPECTOR
as provided in 310 CMR 15.340 and Section 13 of Chapter 21A of the
General Laws. Issued by The Department of Environmental Protection.
lunc 8, 1995
Acting Dircctor of the ton of Watcr Pollution�Coatr�ol
Cy ION
SEWAGE PERMIT . NO.
VILLAGE
'D,A zip
INSTA LLkR'S NAME i ADDRESS
d U I L D E R OR OWNER
Q N, )fl•
DATE PERMIT ISSUED
DAT E COMPLIANCE ISSUED J- �
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No.. :�_3. .� F>a....J�........... ..
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
...... .. ..............OF...
Appliratiun for Disposal Works
Tonstrn.rtiun Errant
Application is hereby made for a Permit to Construct (✓) or Repair ( ) an Individual Sewage Disposal
Systel�
.. tQ SZ`3�e... ............ -....�..................................•--...------............
LL caatio -Address � or Lot No
Own ������//yy//'������-- tt�� ��py� kip
a ............. . ........... .... .......... ..................8.:..`�.'.:...1�:!!4_ _.I__7y ? ._ ®? Y. !V .... ............---_.____........_..^^_
Installer Address y i_7l
S
U Type of Building Size Lot..__....A.................Sq. feet
�-, ms............. ..........................Expansion Attic ( ) Garbage Grinder Dwelling—No. of Bedroo ( )
Other—T e of Building No. of persons............................ Showers
a YP g ---------------------------• P ( )--- Cafeteria ( )
P4Other fixtures -----•------------------------------------------------.-------•-•--•--•••---------------------------------........... ----------
w Design Flow...............5-7r.....................gallons per person per day. Total daily flow--------3-20........................gallons.
WSeptic Tank—Liquid capacity..P�q_.gallons Length__�3___�2_.._._ Width.. {.Sa.__.. Diameter________________ Depth_ ___ ..__.
x Disposal Trench—No. .................... Width.................... Total Length..................... Total leaching area....................sq. ft.
Seepage Pit No.........I.......... Diameter.....11� ........ Depth below inlet... ....... Total leaching area..a�_$7...sq. ft.
Z Other Distribution box ( ) Dosing tank (
Percolation Test Results Performed by.---�o ..*-_ W.eAtA...�.'�:................... Date_..�___!Y _1---------------------.
Test Pit No. 1...15;,-_-_minutes per inch Depth of Test Pit.-AS..........
Depth to ground water------�.............
fT Test Pit No. 2... _....minutes per inch Depth of Test Pit....[AY.k__.... Depth to ground water---___�_.___._.._
a,
x Description of Soil...0•- J4 - o2r.a Sc. z ` �aN �' i - -
-- --------
c.� 7 ... °.. �.------.. ------------------------------------------------------------------------•----------....------------------------............--------
w
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 TITLE 5 of the State Sanitary o e— rsi ne further agrees not to place the system in
operation until a Certificate of Compliance has be ssue b e boa o i 1
Signed
Application Approved BY---.....----•. ---------------- •-----------------------•••-• .............. - -�C ..
Date
Application Disapproved for the f ollowing reasons-------------------------------------------------------•--------------------------------.......................
.................................••••----.....---•••--••-----...........-••---•--._...---------••-......•--.................---••-----•---------------•--•-•--------------••------.
, � Date
PermitNo....... -•---- �•...................... Issued-.......................................................
Date
� s �
r:1 �fi
No................_....... Fim..........................
_
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.........................-.................O F..........................._......._............
ApplirFa#iou for Disposal Works Tons rurtion Wrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
................__.............................................................................. --•--...••-••-••----•---•••----------------•----------•-•••-----------......------.......------•--
Location-Address or Lot No.
.__••__•^__....----•-..............................•--•^----•-•. ...............................
Owner j,� Address
WW1 .................... ......... `-���-f 1_i%4.. ................."^..................................................................................
Installer Address
UType of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—T e of Building g ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures ------•-----•-------------•----....-------------•------••--•••-•---••-••--•••-•-•••••----•-•-----•-_...-•-------•----•-•---••--..._..-----•--••-•-••-
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.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a --•••-•--••--••••••••••••••••-•••••-•-•--•••-•-•......-•-•---•-•....••-•...............................•----•-•--••----•-----•-•-----•--- -•----••---
0 Description of Soil.................................................................................................................................................................................
x
V
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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 TITLE 5 of the State Sanitar de— T dersigned further agrees not to place the system in
operation until a Certificate of Comptliance has be ssue. the bo d eal h.
Signed --- - - ... .•• • --------------•••••••-••-- �
...... Date/... —
Application Approved By............ ........ .............. :. .................................... -------_•--�
Date
Application Disapproved for the ollowing reasons:...............................................................................................................
... ••--•-----••--••--••-•••-------------------•--_--•
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD HEALTH
. �...........O F.....................................................................................
�rr�ifirtt#r ,af �u�t�fitt�trr
'HISR IS TO CEPyTIFY, That the Individual Sewage D`s sal Sy t m constructed ( ) or Repaired ( )
b _
- ---- ; S -s' 'z .. i'14 ; ..�-------------------------
has been installed in accordance with the provisions of TITL_�,j of The State Sanitary Code as 4escribed in the
application for Disposal Works Construction Permit No..._2_ ''_ dated 11-___ _______________
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GU RA TEE THAT THE
SYSTEM WILL FUNC ION SATISFACTORY.
DATE..... ���G..............•------_..... inspector...............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.: ..............................OF..................................................................................... ,
No.•__•_...._.. FEE......:°�..........
0 N Permission i s here-by'granted.__- = ---- -•----- -OLs.-.- - �h .
to Construct ) orRepai ( ) n Indivi SeviT isposal S �t t,
at No '_ .� ��1��St.' 4w------- __------._- '21 Y fS
Street
as shown on the application for Disposal Works Construction Permit No_____________________ Dated..........................................
....................•---•------------••------•--------------------------•-------•--••-•-•--..._---_...._
Board of Health
DATE— ......••••--•-•-•..............• ....:.:.,
FORM 1255 1.'1. SULKIN, INC.. BOSTON '`�.,
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Box
400
LOCAT10N .�3ia�i✓�57�13L � /�1A5 S.
SCALE . .� ".'�° . . . DATE MO. .
PLAN REFERENCE
Spaw.Av v AlPL,!3`G, .39.7. . .
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�= KELLEY
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•,____._.. I CERTIFY THAT THE . .. .....
SHOWN ON THIS PLAN IS LOCATED ON THE GROUND
AS SHOWN HEREON AND THAT IT CONFORMS TO THE
SETBACK REQUIREMENTS OF THE TOWN OF
WHEN CONSTRUCTED.
,7 DATE : . . . . . ... . . . . . .
�T777 REGISTERED LAND SURVEYOR
. . ..... . .. . . ... .
TOP OF FOUNDATION
CONCRETE COVER
CONCRETE COVERS
4"CAST IRON' 2"MAX. � � f
OR SCHEDULE 48 � � 12"MAX.
P.V.C. PIPE 4 SCHEDULE 40 PVC.(ONLY)
PITCH 1/4"PER.FT PIPE - MIN. LEACH
PITCH 1/4"PER.FT. PIT PRECAST
INVERT -� LEACHING
° EL••`�.y r`f. INVERT INVERT 'o . ��; PIT OR
D , SEPTIC TANK DIST. Sgg w EQUIV.
INVERT . . BOX EL..., L. ' : >s
/000 GAL. INVERT 3•SF-►- '�•
' ' ' ' INVERT v a 0' .:6" 3/4"TO I V2
EL�`14.3. wW 0:
ELS8,70. :.' �0 v. WASHED
STONE
�7I b 30'—►�+—6'DIA.
DIA
PROFILE OF _GROUND WATER TABLE
SEWAGE DISPOSAL SYSTEM
NO SCALE
P- 3117
SOIL LOG WITNESSED BY :
DATE !`> •%f�`�8¢ BOARD OF HEALTH
TEST HOLE I TEST HOLE 2 4-0W, 04 r72 .T��', . ENGINEER
ELEV. ../I.$4. . . . ELEV. G¢79 . . .
1-727
Goq+-j T\\" 7
DESIGN DATA :
c 7 Boz, C2,7oNUMBER OF BEDROOMS
-TxG Z) gNp TOTAL ESTIMATED FLOW -330. . . . GALLONS/DAY
67, 7o BOTTOM LEACHING AREA /�349. SQ.FT. /PIT/G PD,
SIDE LEACHING AREA . .�3�9. . . . SQ.FT./ PIT/.�Z9' C,p,D,
,S p GARBAGE DISPOSAL .�✓�'!/�. .(50% AREA INCREASE)
Ste,p Z¢',5;b
TOTAL LEACHING AREA . . . . . . . . SQ.FT
/68N LrL, b3,Bo /�8" tio,7v PERCOLATION RATE s5 7?W✓.7)✓O MIN/INCH
No. .WATER ENCOUNTERED LEACHING AREA PER PERCOLATION RATE - SQ.FT/CA,D,
NUMBER OF LEACHING PITS . a^�C. !�/77 W!77I.
APPROVED . . . . . . . . . . . . BOARD OF HEALTH •77IA24°- F� ?-.oF J5 vvve oAl !ALL
S/Z>cs
DATE . . .
AGENT OR INSPECTOR
OF�Ass9
„eb EDW
v3 R H
N 26100 O y N 7
01STEP a FD
!577* � SORAOT
PETITIONER B�,L/`CG�/ C�ci7LD�7ZS