HomeMy WebLinkAbout0166 DROMOLAND LANE - Health 166 Dromoland Ln. , Barnstable
A= 335-081
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'p r, TOWN OF BARNSTABLE , 0
LC?C,14T i ION 146 7DRr-m1.5L4A 1' Lam. SEWAGE # 97 .-Z99
VILLAGE 3t)PrJiTrA;3 J P ASSESSOR'S MAP & LOT 33.5`D�
INSTALLER'S NAME&PHONE NO. WI S fi R OT C WS-r. 36 2 3 7
SEPTIC TANK CAPACITY /GILL
LEACHING FACILITY: (type)
S� btYcOe-LC. (size) l 12�,X ay,'
NO.OF BEDROOM?S� '7 BUILDER OR WNE13J �Q-�t�anL I/ICr YeI/y�111,. �S
PERMIT DATE: f�%!.&Z 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 Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
7 5 Cf ►��,
, q
Y 'l
� s
Fee
THE COMMONWEALTH OF MASSACHUSETTS
2 PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
3ppricatiou for Ziopozar 6potem Conotruction Permit
Application is hereby made for a Permit to Construct( )or Repair(4-/)an On-site Sewage Disposal System at:
Location Address or Lot No. Owner's Name,Address and Tel.N .
De
Installer j aan, Address Designer's Name,Address and Tel.No. j� .� i7jh
Type of Building:
Dwelling No.of Bedrooms Garbage Grinder
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fiixtures -�
Design FLOOD gallons per day. Calculated daily flow 1 " gallons.
Plan Date Number of sheets Revision Date
Title - ,
Description of Soil
Na of Rep 'rs or terati 3yswer when applicably � � i
-, i✓L.s t
Date last inspected:
Agreement:
The undersigned agrees to ensure the cons" 'on and maintenance a afore described on-site sewage disposal system
in accordance with the provisions of Title 5 nvironmental Co d no_jt/to place the system in operation until a Certifi-
cate of Compliance has been issu oard of Health. _ _
Signed �`� Date
Application Approved by zle
Application Disapproved for the following reasons
7' a2�f Permit No._� Date Issued
lNry f• ?1 -
! /y9 Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
0(ppYication for Mtgpo5al bpgtem Construction Permit
Application is hereby made for a Permit to Construct( )or Repair(V)an On-site Sewage Disposal System at: �.
Location Address or Lot No. Owner's Name,Address and Tel N
( Installer' .blame Address,and Tel'No: - ` 4 Designer's Name,Address and;Tel.No. c-°"3
I
Type of Building: ..
Dwelling No.of Bedrooms Garbage Grinders
Other Type of Building `No.of Persons _ Showers( ) Cafeteria( )
OtherFixtures
Design Flofv//i�Z gallons per day. Calculated daily flow er gallons.
Plan Dat& Number of sheets Revision Date
r�
- Title'!
Description of Soil
aof Repairs orterat nsAnswer when applicable) s t / c z?
i
.! t3i a r
� ' 4-v v/ vim-- �vt n 1,1.,3
Date last inspected:
Agreement: t
The undersigned agrees to ensure the constru 'on and maintenance e afore described on-site sewage disposal-system
in accordance with the provisions of Title 5�°�vironmental Codet'Aid no'C:to place the system in operation until a Certifi-
cate of Compliance has been issu kFrSBoard of Health.
Signed - Date
a.
Application Approved by
Application Disapproved for the following reasons
Permit No. ?r vZ 7 Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION BARNSTABLE. MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERIVY t at the On-site Sewage Disposal System installed( )or repaired/replaced(Z)o
by i'y, 'yycs...�... = for
a� V-0 Pwn 1 04-v►S has seen constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. dated
Use of this system is conditioned on compliance with the provisions set forth below:
TF
No.
g7- a Fee
9� sv
� '
THE COMMONWEALTH OF MASSACHUSETTS i
PUBLIC HEALTH DIVISION BARNSTABLES MASSACHUSETTS
Migogar *potem Construction Permit
Permission is hereby granted to
to construct( )repair( k)an On-site Sewage System located at Z6 o _4d )
w;
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
All construction must be completed within two years of the date below.
Date: ;/w 7 Approved by
,f
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_•: 508.36221 F,g MCABEE REAL ESTATE PAGE 02
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CERTIFIED PLOT PLAN
LOCATION
yCaLE . . . �
DAT .T Z
� I
�1._Ati' REFERETICE
P
I
1• I
THAT THE
-10ti+S ON THIS PLAN IS LOCATED ON THE GROUND
5- -&N HEREON AND THAT IT CONFORMS TV THE
T8 CK REOUIREMENTS OF THE TOWN OF �I'p
WHEN CONSTRUCTED. D
'E L. V,/�17
REOISTERED 'LAND SURVEYOR
5 508i : 2'2159 MCAEEE REAL ESTATE PAGE 0
TOP OF FOUNDATION
T CONCRETE COVER
I CONCRETE COVERS
g o1 4"CAST IRON JJ2 MAX. 77-, rrn
,'•, OR SCHEDULE 4p � 12"MAX.
4" SCHEDULE
P C E 40 PVC, ONLY
V.C. PIPE �
' PITCH 1/4"PER. PIPE - MIN. LEACH
o .
PITCH I/4"PER.FT PIT PRECAST
INVERT [' J LEACHING
° EL.., 'rf INVERT INVERT i ! �•� PIT OR
SEPTIC TANK S cS DIST. Pt I w EOUIV.
INVERT EL.., ! . . . . , BOX EL, ...7, _>_
S inoD... . GAL . INVERT INVERT G , w o 3/a"TO I I/2
r�
EL.. ZL. E LF. •9`f U4
WASHED
.� STONE
E
PROFI LE OF AGROUND WATER TABLE
SEWAGE DISPOSAL SYSTEM
NO SCALE
SOIL LOG WITNESSED-. BY
DATE J� BS TIME . /Q.to*. M . !yCk!E" +./. BOARD OF HEALTH
TEST HOLE I TEST HOLE 2 <_'pWi9lzQ 4'. eLrLGL°y ENGINEER
ELEV. •.60 ELEV. .S4.�?
ko�,:v`ca� /c s�e•so;C, DESIGN DATA
NUMBER OF BEDROOMS
SAD . s �Dtiic TOTAL ESTIMATED FLOW 33o GALLONS/DAY
ln/i7}l BOTTOM LEACHING AREA "5° SO,FT. / PIT/C.P A.
FjNes 78 �rz q�A> SIDE LEACHING AREA SO.FT./ PIT/4, 7/
GARBAGE DISPOSAL 50 % AREA INCREASE)
Se- TOTAL LEACHING AREA 7. gip. SOFT
PERCOLATION RATE ` A . MIN/INCH
Sb^I e2..Q/.S~o eL.47.'70
LEACHING AREA PER PERCOLATION .RATE ' P, . SO.FT/4---PP
WATER ENCOUNTERED
NUMBER OF LEACHING PITS ?�/� PST k//7i�
APPROVED . . . HOARp OF .HEALTH !� � aF,S7?a"IeT 4.v A-ZG
DATE : . .
AGENT OR INSPECTOR
30L V,VS7P -�?4 l Jf l
PETITIONER (�- �,-
51=1=13 622169 h1CABEE REAL ESTATE PAGE 04
APP1,ICAT)ON VOR rrRC01,ATION Tr.51' AND OBSCRVATION PTT^
)CATION . .� ^f'---
LI,AGf; QAYPn/ST.�BLd- DATE
.S
rLICAN'f
P•C(:` 1
'DRESS f inns �fyq 5S TCLEPHONE NO. (Non-refund<b1e)
GINECR A9t �'�u�[ -TELEPHONE No.
TE SCHEDULED
tApplicant'a Signature)
. .
PA-'-so e4 ' p SOIL LOG
D-DIVISION NAME Le.BL! .5 ' DATE �?N }/. /yes' TIME /o:c,n1.7
PANSI6N AREA: YES_✓NO DLV'-g1z-0 sr, F.NGINF,.CR
WN WATCR�PRIVATC WCLL_ `TD�j y�,(��q-ram BOARD OF HFAT.,TH
17XCAVATOR
ETCH: (Street name,etC. ,dimensions of lot, exaCt locatioll 'of, test hole9 and
percolation tests, locate wetlands in proximity to tent }iole9)
NOTES:
LoT Ar Z/ -
9? 4fd sop.Fr
if Z- ✓ tN
- 7,79 �9 I
'6
.a
d 1
4plti!
f�H
tCOLATION RA C: «,55 71-1,9. r>^ Nin 1,v I
;T HOLC NO:
1 " / ELEVATION: TEST HOLE NO: 2- ELEVATION: �I
1 F �.- C7DP•Soi4 .. - 1 JAB- Soil -
2 2 /L r
3 _. 3 nN�
4 4 ..
5 ,yry�F,�E 5
6 Sawa
7 W,ry 7 78
6 -Sa•►� H ,..
9 - NCS 9 M6'D�CaAn3tf
10
11 11 —
12 12 -
13 13
�n ,
' 14 '1 '14
IS 15
16 / 16
TABLE FOR sUD-SURFFB SCWAGE: LEACHING FIELt) LEACHING PITS_✓
LEACHING TRENCHES
:UITADLC rOR SUU.SURRACE SrWhGE, REASONS; -
•E: ENGINC1-:1UNG PLANS MUST SHOW NUMBER,ASSIGNED ON PFRC TEST APPLICATION
.GINAL: Comp, . , ) 7I7 F,N7jRf:',1;X TSY P, E, 'AND RETURNED TO B0ARD OF IIf:ALTII
y, IWI) nY Arrl,irANT I
NOTICE: This Form is to be used for the Repair of Failed
Septic Systems Only
{r,
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS)
}hereby certify that the application for disposal-works
constructio �ermiLt`signed by me dated { concerning the
property located at .`JG 'C� `'�1�� / J� ' meets all of the
r
`following criteria: s�
• There are no wetlands within 300 feet of the proposed septic system
• There are no private wells within 150 feet of the proposed septic system
• The'observed groundwater table is 14 feet or greater below the bottom of the leaching facility -
• There is no increase in flow and/or change in use proposed
'G , • There are no variances requested or needed. ,
SIGNED : /L/L r DATE:
f r LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER"
[Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan,
,this plan should be submitted].
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'oo! 2� —
TOWN OF BA.RNSTABLE
LOCATION bt?ninOLk)n)h L.t) SEWAGE #
VILLAGE P►1 r'i931 F' ASSESSOR'S MAP & LOT ZZIZ :
INSTALLER'S NAME&PHONE N0.Ut/S 13f2oS Ca,)ST• 3G -ta 3'7
SEPTIC TANK CAPACITY I00--
LEACHING FACILITY: (type)
,SiV bt YgJefC. (size) l oZX 2y
NO.OF BEDROOMS T /
BUILDER OR 7
PERMITDATE: COMPLIANCE DATE: 6 —
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 Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
1.G.AtA f E
0
Commonweafth of Mossochusetts
Executive Office of ErMonniental Affairs .John Grad
Dep
D.E.P. Title V Septic.htispector
a rime y P.O. Box 2119
EnvIronmental Prafteftn, Teaticket,MA 025 36.
(508) 564-6813
�T 12 1 SUBSURFACE SEWAGE DISPOSAL
ASYSTEM INSPECTION FORM
P
„ CERTIFICATION
166 Dromoland Lane Cumma uid
Property Address: Address of Owner: °
Date of Inspection:58197 q. .�
(If different) €�jd •l99
Name of Inspector:John Gracl Hellebrekers Box 73 Cummaquld
Company Name,Address and Telephone Number:
4
CERTIFICATION STATEMENT
I certify that 1 have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system: ?
Passes This Inspection Is based on criteria defined in Title V
— Conditionally P sses code 310 CMR 15.303.My findings are of how the system is
_ Needs F h valuation By the Local Approving Authority,
Performing at the time of the Inspection.My Inspection does
X Falls not Imply any warranty or guarantee of the longevity of the
septic system and any of its components useful life.
Inspector's Signature:
Date: 518197
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspections. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector,and the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection. ?
The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority.
X
INSPECTION SUMMARY: , £..
Check A, B,C,or D:
A] SYSTEM PASSES: l
I have not found any information which indicatesf that the system violates any of the'failure,criteria
defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below.
B] SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system,upon completion
of the replacement or repair,passes inspection.
Indicate yes,no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If '!not,determined",~explain why not.)
The septic tank is metal, 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 11115195)
One Winter Street 9 Boston,Massachusetts 02108 9 FAX(617)556-1049,,• Telephone(617)292.5500
1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A U
CERTIFICATION (continued)
Property Address: 166 Dromoland Lane Cummaquid
Owner: Hellebrekers Box 73 Cummaquld
Date of Inspection:5fW97
_ Sewage backup or breakout or high static water level observed in the distribution box is due to a broken,~
settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
—The system required pumping more than four times a year due to broken or obstructed pipe(s). The
system will pass inspection if with approval o al( pp f the Board of Health):
broken pipe(s)are replaced
obstruction is removed
C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the
system is failing to protect the public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS
NOT FUN
CTIONING IN A MANNER WHICH
WILL PROTECT THE
SAFETY AND THE ENVIRONMENT: PUBLIC HEALTH AND
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER, IF APPROPRIATE)DETERMINES
THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT: r
The system has a septic tank and soil absorption system and is within 100 feet to a
surface of water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and is within a Zone 1 of a public water
supply well.
— The system has a septic tank and soil absorption system and is within 50 feet of a private water
supply well.
The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private
water supply well,unless a well water analysis for coliform bacteria volatile organic compounds indicates that the well is
free from pollution for that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm.
u 3) OTHER
D) SYSTEM FAILS:
I have determined that the system violates one'or more of the following failure criteria as defined in
310 CMR 15.303.
. 03. The basis for th
is determination is ide
ntified below. The
Board of Health should be
contacted to determine what will be necessary to correct the failure.
Backup of sewage in facility or system component due to an overloaded or clogged SAS or
cesspool.
Discharge or poriding of effluent to the surface of the ground or surface waters due to an overloaded or cloyyed
cesspool.
X SAS is in hydraulic failure.
(revised 11115195)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 166 Dromoland Lane Cummaquld
Owner: Hellebrekers Box 73 Cummaquld
Date of Inspection:519197
D] SYSTEM FAILS(continued)
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Numbers of times pumped
Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of.a surface water supply'ortributary to La surface water supply.
Any portion of a cesspool or privy is within a Zone L 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: ,
The following criteria apply to large systems inaddition to the criteria:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
the system is within 400 feet of a surface'drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone II of a
public water supply well)
The owner or operator of any such system shall bring the system and�facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 11115195)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART 8
CHECLIST `
Property Address: too Dromoland Lane Cummaquld
Owner: Hellebrekers Box 73 Cummaquld „
Date of Inspection:518197
Check if the following have been done: a
x Pumping information was requested of the owner,occupant,and Board of Health.
X None of the system components have been pumped for at least two weeks and the and the system has been receiving normal
flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this _
inspection.
n1aAs built plans have been obtained and examined. Note if they are not available with N/A.
X The facility or dwelling was inspected for signs of sewage back-up.
X The system does not receive non-sanitary or industrial waste flow.
x The site was inspected for signs of breakout.
X All system components,excluding the Soil Absorption System,have been located on the site. 1
X The septic tank manholes were uncovered,opened,and the Interior of the septic tank was Inspected ,
for condition of baffles or tees,material of construction,dimensions,depth of liquid, depth of sludge, depth of scum.
X The size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub-
Surface Disposal System. E
9.' -' a ..- - ..- -•
T Fi
ti
(revised 11115195) -
= a
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 188Dromoland Lane Cummaquld
Owner: Hellebrekers Box 73 Cummaquld _
Date of Inspection:5IW97 t.
Al
FLOW CONDITIONS
RESIDENTIAL: v
Design flow: "D gallons
Number of bedrooms: 4
Number of current residents:
Garbage grinder(yes or no): No
Laundry connected to system(yes or no): Yes
Seasonal use(yes or no): No y
Water meter readings,if available: nla
Last date of occupancy: n1a
COMMERCIAL/INDUSTRIAL: f
Type of establishment: We
Design flow:8 gallons/day
Grease trap present:(yes or no) No m
Industrial Waste Holding Tank present:(yes or no) No
Non-sanitary waste discharged to the Title 5 system:(yes or no) No
Water meter readings,if available: n1a
Last date of occupancy: nla _
OTHER:(Describe) Na
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information; -
System has not been pumped In the last year.
System pumped as part of inspection:(yes or no)No
If yes,volume pumped:o gallons
Reason for pumping: n1a
TYPE OF SYSTEM
X Septic tank/distribution box/soil absorptions system
Single cesspool
Overflow cesspool '
Privy h
Shared system(yes or no) (if yes,attach previous inspection records,if any)
Other(explain)
APPROXIMATE AGE of all components,date installed(if known)and source information:
1988
Sewage odors detected when arriving at the site:(yes or no) No
(revised 11115195) "t
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued) +
Property Address: 166 Dromoland Lane Cummaquid
Owner: Hellebrekers Box 73 Cummaquid'
Date of Inspection:5M97
SEPTIC TANK: x
(locate on site plan) -
Depth below grade: 16"
Material of construction:X concreate_metal_FRP_other(expiain) `
Dimensions: L 8'6-H 5 7"W 4'16"
Sludge depth:3" -
Distance from top of sludge to bottom of outlet tee or baffle: 24"
Scum thickness:3"
Distance from top of scum to top of outlet tee or baffle:6'
Distance form bottom of scum to bottom of outlet tee or baffle: 15" '
Comment s:
recomm '( endation 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.)
The septic tank and all components are structurally sound.Recommend pumping the system every two years for maintenance.
GREASE TRAP_
(locate on site plan)
Depth below grade: n1a
Material of construction: _concrete_metal_FRP_other(explain)
Dimensions: n1a "
Scum thickness:Ma
Distance from top of scum to top of outlet tee or baffle:nla
Distance from bottom of scum to bottom of outlet tee or baffle:n1a
Comments: 1
(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.)
Na r
(revised 11J15195) s
er
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 166 Dromotand Lane Cummaquid
Owner: Hellebrekers Box 73 Cummaquld
Date of Inspection:519197
s
TIGHT OR HOLDING TANK:
(locate on site plan)
i
Depth below grade: nla
Material of con struction:_concrete_metal_FRP_other(explain)
Dimensions: n1a
Capacity: n1a gallons `
Des' • n1a
Design flow.
g
—gallons/day
,
Alarm level: n1a
Comments:
(condition of inlet tee,condition of alarm and float switches,etc:)
Na
DISTRIBUTION BOX:
(locate on site plan) w:
Depth of liquid level above outlet invert: n1a
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box etc.)Na
PUMP CHAMBER:
(locate on site plan)
Pumps in working order:(yes or no) °k
Comments: r:
(note condition of pump chamber,condition of pumps and appurtenances, etc.)
n1a
v .
(revised 11115195)
a
i .. - ` ;,. a •�« �. ..f _ -
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 166 Dromoland Lane Cummaquld
Owner: Hellebrekers Box 73 Cummaquld
Date of Inspection:51907
SOIL ABSORPTION SYSTEM(SAS):X
(locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods)
If not determined to be present,explain:
Na
Type: "
leaching pits,number: 1,000 gallon leach pit
leaching chambers,number:Na 3
leaching galleries,number: n1a
leaching trenches,number,length: n1a
leaching fields,number,dimensions:n1a
overflow cesspool,number:n1a
Comments:(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) J
The leach pk Is past the effective depth of leaching.The sas is in hydraulic failure The pit is full
CESSPOOLS:
(locate on site plan) -
Number and configuration: Na
Depth-top of liquid to inlet invert: Na
Depth of solids layer: n►a
Depth of scum layer: Na
Dimensions of cesspool: n1a
Materials of construction: n1a
Indication of groundwater: n1a
Na
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.)
Na
PRIVY:_
(locate on site plan)
Materials of construction: nla Dimensions:' n1a
Depth of solids: n►a
Comments:(note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation,etc.)
Na
(revised 11115195)
F .
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 166 Dromoland Lane Cummaquid
Owner: Hellebrekers Box 73 Cummaquld
Date of Inspection:518197
SKETCH OF SEWAGE DISPOSAL SYSTEM: F
include ties,to at least two permanent references landmarks or benchmarks
locate all wells within 100'
-------------
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F J
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6A '7
to �oaU
DEPTH TO GROUNDWATER
Depth to groundwater:12 feet
method of determination or approximation:
USGS Maps and Charts
(revised 11115195)
' L0.,-;: AfI'ON �� SEWAGE PERMIT N0.
YI- LLAGE
1019
3
I N S T A LLER'S NAME A ADDRESS
D U I L D E/R OR OWN ER
DATE P.ERIRIT ISSUED K5
DATE COMPLIANCE ISSUED
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............ ..............................OF.............................................................................------------
Appliration for Uhipoiial WorkgConstrurtion ramit
Application is,hereby made for a Permit to Construct (-K) or Repair an Individual Sewage Disposal
'System at:
------------
4,ocai5�tddr ess —7 7.'7
to.
-
.. .............. ................ .................. ...... ...............
. ..................0
0)01- J Address
.................................................. .................. ...................................................................................................
Installer Address
Type of Building Size Lot............................Sq. feet
U
Dwelling—No. of Bedrooms............................._..__......Expansion Attic Garbage Grinder ( ^1)0
Other—Type of Building ............................ No. of persons............................ Showers Cafeteria (
Otherfixtures --------------------------------------------------------------------------------------------------------------------------------------------0.........
Design Flow............................................gallons per person per day. Total daily flow._..........-a-P......................gallons.
1:4 'Septic Tank—Liquid capacity Zo_0_1.0..gallons Length................ Width._.._....._._... Diameter.-._--_---_..... Depth....__..__...__.
'.Disposal Trench—No. .................... Width.....___.._..___._.. Total Length.................... Total leaching area-___:�,.&.-7__sq. ft.
Seepage-Pit No..................... Diameter.........G....... Depth below inlet......6..1....... Total leaching area..................sq. ft.
Z -Other Distribution box Dosing tank
-Percolation Test Results Performed by................C.0..J!
--- -----------------------
--- Date............._......._______......_..__.
Test Pit No. 1...:4._Q-..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........................
--------------------------------------jp•------------- . .............................................1.��..........................
0 .........................
.Description of Soil...........ref .......W........
U .............................. . ............. ....... .......... 2........ ...........................................................................
W
---------------------------------------................................................................................................................................................................
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 TL I TL LE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
oper ion un I a Ger-tificate of Compliance
pliance has en issued 6 t �ar of health.
-.,L........................
By......... . I.. .........
Signed. ...3.......
ication Approved Date
........ ...
..... .................I----- .....
D.7
Application Disapproved for t following reasons:............................................................... ............................................
........................................................................................................................................................................................................
Date
Permit No......... ..... . 17.I... ..................... Issued....... .... ..........
Date
—---------------------
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CERTIFIED PLOT PLAN`
a I I
LOCATION . B�IZNSTABL�� MASS - _ 1
SCALE . / _. ,� �. . . . BATE T!1?`!. Z�.��B�. I A
PLAN REFERENCE
Sf�ow.y oN Ale,49 oFcc
ED%ARgj 1
s ALLEY - 1
.26100
OIST�P�� 1 I
CERTIFY THAT THE ... ,....
SHOWN ON THIS PLAN IS LOCATED ON'THE OROUND rt
AS SHOWN HEREON AND THAT IT CONFORMS TO THE
SETBACK REOUIREMENTS, OF THE TOWN OF 2p
WHEN CONSTRUCTED. p
DATE . . . . . . w"�o1
REGISTERED LAND SURVEYOR
L. . GZ _0. . ...
TOP OF FOUNDATION
CONCRETE COVER
CONCRETE COVERS
g o1 a 4"CAST IRON 12 A' 12"MAX.
OR SCHEDULE 4d 4"SCHEDULE 40 PV.C.(ONLY)
P.V.C. PIPE PIPE- MIN. LEACH
PITCH 1/4"PER. PITCH I/4"PER.FT.
„e PIT PRECAST
e' NVERT '� LEACHING
;.c
e EL...•� 'i�.3. \—INVERT INVERT ! w f:; PIT OR
a'. SEPTIC TANK DIST. EQUIV,
INVERT EL..,S¢,.od7 BOX EL—7Z• ' : > :•:
EL..� �zL•. . ../aoC.. .. GAL. INVERT G' « «
EL�399� INVERT v 0: r�. 3/4 TO 1 V2
ELAZ-& ;. o �: WASHED
e L.
STONE
•• dFZ.�•9b •.
• 4-2l---+��--S'DIA. —►-� n�1�✓t
• . . - /o' DIA.. Awe cK"
f'ROR LE OF GROUND WATER TABLE
SEWAGE DISPOSAL SYSTEM
NO SCALE
SOIL LOG WITNESSED BY°:
DATE Tq'!�. !; 14as TIME./v:.00 A?Y ToM gr/. BOARD OF HEALTH
TEST HOLE I TEST HOLE 2. ,ENGINEER
ELEV. . .S�f•So . . ELEV. -f4-y4.
DESIGN - DATA '
HL•D/ENE -NUMBER OF BEDROOMS: 3
SA�✓D M���NE TOTAL ESTIMATED FLOW 330. GALLONS/DAY r
SotiE BOTTOM LEACHING AREA : 78�� SQ.FT. /PI vC P P.
78
FlNE3 ,¢B,� SIDE LEACHING AREA 466•�07. . . . SQ.FT./'PIV47/C.P,D,
GARBAGE DISPOSAL ,Ne.t/� (50%'AREA INCREASE)
TOTAL LEACHING AREA SQ.FT
,SAND
It �` PERCOLATION RATE �`3S. /� ! 7WP; MIN/INCH
Z.¢i sd 144 �z.4z.yo . -
WATER ENCOUNTERED ' LEACHING 1.AREA PER PERCOLATION RATE .-'�XO.. SQ.FTIC.PA
.... . .
NUMBER OF LEACHING PITS . �Wf. I�iTW!T7�
APPROVED . . BOARD OF HEALTH •7ES/.0 ; .1:j_�
DATE . .: • ,S/D�. . . - . .. . . � -, -: — - -
f' AGENT OR INSPECTOROF CF
ED
GOT Z t
G�1LL
. V LLEY —1 .527
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PETITIONER �'�� ?L�s�Gw, J�•�?C,,