HomeMy WebLinkAbout0135 STONEY POINT ROAD - Health 135 STONEY POINT RD., BARNSTABLE
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TOWN OF BARNSTABLE
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'. INSTALLER'S NAME&t PHONE NO.
f SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) Pt (size) kQM r4 ft
NO.OF BEDROOMS
BUILDER OR OWNER :JkVQKNN S
Waffiff DATE: 6\2'A� COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) 1�h Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
_ within 300 feet of leaching facility).. Feet
Furnished by ��
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COMMONWEALTH OF MASSACHUSETTS `X
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
F DEPARTMENT OF ENVIRONMENTAL PROTECTI I;i.
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TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
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Property Address: 135 STONEY PT. CUMMAQUID,MA 02637 L13
Owner's Name: NIEMI C/O REALTY EXECUTIVES
Owner's Address: 1330 PHINNEYS LANE HYANNIS ATT.CARMEL
Date of Inspection: 5/15/01
Name of Inspector: (please print) JOHN GRACI
Company Name: SEPTIC INSPECTIONS
Mailing Address: r P.O. BOX 2119 TEATICKET,MA.02536
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Telephone Number: 508-564-6813 FAX 508-564-7270
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is
true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and
experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system
inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
X Passes
_ Conditionally Passes
_ Needs Furt r valuation by the Local Approving Authority
Fails
Inspector's Signature: Date: 5/15/01
The system inspector shall submit copy of this inspection report to the Approving Authority(Board of Health or DEP)within
30 days of completing this inspect on. If the system is a shared system or has a design flow of 10,000 gpd or greater;the
inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be
sent to the system owner and copies sent to the buyer, if applicable,and the approving authority.
Notes and Comments
THE SYSTEM PASSES TITLE V INPECTION.RECOMMEND PUMPING SYSTEM EVERY TWO YEARS TO
PROLONG THE SYSTEM'S USEFULL LIFE.
****This report only describes conditions at the time of inspection and under the conditions of use at that time. This
inspection does not address how the system will perform in the future under the same or different conditions of use.
Title 5 IncnPrtinn Fnrm FBI snnnn I
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 135 STONEY PT.CUMMAQUID,MA 02637 L13
Owner: NIEMI C/O REALTY EXECUTIVES
Date of Inspection: 5/15/01
Inspection Summary: Check A,B,C,D or E/AA WAYS complete all of Section D
A. System Passes:
X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310
CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments: Y'
THE SYSTEM PASSES TITLE V INPECTION. RECOMMEND PUMPING SYSTEM EVERY TWO YEARS TO
PROLONG THE SYSTEM'S USEFULL LIFE.
B. System Conditionally Passes:
_ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,
upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain.
n/a The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits
substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced
with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating
that the tank is less than 20 years old is available.
ND explain: n/a
n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed
pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of
Health):
_ broken pipe(s)are replaced
_ obstruction is removed
_ distribution box is leveled or replaced
ND explain: n/a
n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass
inspection if(with approval of the Board of Health):
_broken pipe(s)are replaced
_obstruction is removed
ND explain: n/a
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 135 STONEY PT.CUMMAQUID,MA 02637 L13
Owner: NIEMI C/O REALTY EXECUTIVES
Date of Inspection: 5/15/01
C. Further Evaluation is Required by the Board of Health:
_ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to
protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is
not functioning in a manner which will protect public health,safety and the environment:
_ Cesspool or privy is within 50 feet of a surface water
_ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
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2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water
supply or tributary to a surface water supply.
_ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
_ The system has a septic tank'and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and'SAS and the SAS is less than 100 feet but 50 feet or more from a private water
supply well". Method used to determine distance n/a
"This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and
volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy
of the analysis must be attached to this form.
3. Other:
n/a
3,
E
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Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 135 STONEY PT. CUMMAQUID,MA 02637 L13
Owner: NIEMI C/O REALTY EXECUTIVES
Date of Inspection: 5/15/01
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all-inspections:
Yes No
_ X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged
SAS or cesspool
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool'
X Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times
pumped nLa.
X Any portion of the SAS,cesspool or privy is below high ground water elevation.
X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool or privy is within a Zone I of a public well.
_ X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with
no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP ,
certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free
from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be
attached to this form.]
(Yes/No)The system faffs. I have determined that one or more of the above failure criteria exist as described in 310
CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary to a surface drinking water supply
X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat
under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
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Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 135 STONEY PT. CUMMAQUID,MA 02637 L13
Owner: NIEMI C/O REALTY EXECUTIVES
Date of Inspection: 5/15/01
Check if the following have been done.You must indicate"yes" or"no" as to'each of the following:
Yes No
X _ Pumping information was provided by the owner,occupant,or Board of Health
X Were any of the system components pumped out in the previous two weeks?
X _ Has the system received normal flows in the previous two week period?
X Have large volumes of water been introduced to the system recently or as part of this inspection'?
X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
X _ Was the facility or dwelling inspected for signs of sewage back up?
X _ Was the site inspected for signs of break out'?
X _ Were all system components,excluding the SAS, located on site
X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the
baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance
of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
X _ Existing information. For example,a plan at the Board of Health.
X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is
unacceptable)[310 CMR 15.302(3)(b)]
r ,
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 135 STONEY PT.CUMMAQUID,MA 02637 L13
Owner: NIEMI C/O REALTY EXECUTIVES
Date of Inipection: 5/15/01
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):330
Number of current residents: 2
Does residence have a garbage grinder(yes or no): NO
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no): NO .
Seasonal use: (yes or no): NO
Water meter readings, if available(last 2 years usage(gpd)): n/a
Sump pump(yes or no): NO
Last date of occupancy: n/a
COMMERCIAL/INDUSTRIAL
Type of establishment: n/a
Design flow(based on 310 CMR 15.203): n/agpd
Basis of design flow(seats/persons/sgft,etc.): n/a
Grease trap present(yes or no): NO
Industrial waste holding tank present(yes or no): NO
Non-sanitary waste discharged to the Title 5 system(yes or no): NO
Water meter readings, if available: n/a
Last date of occupancy/use: n/a
OTHER(describe): n/a
GENERAL INFORMATION
Pumping Records
Source of information: n/a
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: n/agallons--How was quantity pumped determined?n/a
Reason for pumping: n/a
TYPE OF SYSTEM
X Septic tank,distribution box,soil absorption system
_Single cesspool
_Overflow cesspool
_Privy
_Shared system(yes or no)(if yes,attach previous inspection records, if any)
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from
system owner)
Tight tank Attach a copy of the DEP approval
Other(describe): n/a
Approximate age of all components,'date installed(if known)and source of information:
APPROX. 1990
Were sewage odors detected when arriving at the site(yes or no): NO
Page 7 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 135 STONEY PT. CUMMAQUID,MA 02637 L13
Owner: NIEMI C/O REALTY EXECUTIVES
Date of Inspection: 5115/01
BUILDING SEWER(locate on site plan)
Depth belowgrade: 72"
Materials of construction:_cast iron X40 PVC_other(explain): n/a.
Distance from private water supply well or suction line: n/a
Comments(on condition of joints,venting,evidence of leakage,etc.):
TOWN WATER
.N
SEPTIC TANK: X(locate on site plan) ,
Depth below grade: 66"
Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a
If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate)
Dimensions: 1000G L 8'6" H 5' 7" W 4' 10""
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 32"
Scum thickness: 2"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom'of'outlet tee or baffle: n/a
How were dimensions determined: MEASURED
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
THE SEPTIC TANKS AND ALL COMPONENTS ARE STRUCTURALLY SOUND. RECOMMEND PUMPING
SEPTIC SYSTEM EVERY TWOYEARS TO PROLONG THE SYSTEM'S USEFULL LIFE.
GREASE TRAP:_(locate on site plan)
Depth below grade:n/a
Material of construction:_concrete_metal_fiberglass_polyethylene—other(explain): n/a
Dimensions: n/a
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
Date of last pumping: n/a
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
n/a
. t
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Page8ofII
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 135 STONEY PT. CUMMAQUID,MA 02637 L13
Owner: NIEMI C/O REALTY EXECUTIVES
Date of Inspection: 5/15/01
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) '
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n%a
Capacity: n/a gallons
Design Flow: n/a gallons/day
Alarm present(yes or no): N/A
Alarm level: N/A Alarm in working order(yes or no): NO
Date of last pumping: n/a
Comments(condition of alarm and float switches,etc.):
n/a
DISTRIBUTION BOX:X(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE
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.):
THE DISTRIBUTION BOX IS STRUCTURALLY SOUND.
PUMP CHAMBER:_(locate on site plan)
Pumps in working order(yes or no): NO
Alarms in working order(yes or no):NO
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
n/a
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Page 9 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 135 STONEY PT.CUMMAQUID,MA 02637 L13
Owner: NIEMI C/O REALTY EXECUTIVES
Date of Inspection: 5/15/01
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
n/a
Type
1000 GAL 6' X 6', leaching pits, number: 1
n/a leaching chambers, number: n/a
n/a leaching galleries, number: n/a
n/a leaching trenches, number, length: n/a
n/a leaching fields, number: n/a
n/a overflow cesspool, number: n/a
n/a innovative/alternative system
Type/name of technology: n/a
Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.):
THE LEACH PIT IS STRUCTURALLY SOUND AND APPEARS TO BE FUNCTIONING PROPERLY.THE PIT
HAD 2' OF WATER IN AT THE TIME OF THE INSPECTION.
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: n/a
Depth—top of liquid to inlet invert: n/a
Depth of solids layer: n/a
Depth of scum layer: n/a
Dimensions of cesspool: n/a
Materials of construction: n/a
Indication of groundwater inflow(yes or no): NO
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
PRIVY: (locate on site plan)
Materials of construction: n/a
Dimensions: n/a
Depth of solids: n/a
Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
4
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 135 STONEY PT.CUMMAQUID,MA 02637 L13
Owner: NIEMI C/O REALTY EXECUTIVES
Date of Inspection: 5/15/01 +
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.
Locate all wells within 100 feet. Locate where public water supply enters the building.
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Page I I of 1 1
A
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 135 STONEY PT.CUMMAQUID,MA 02637 L13
Owner: NIEMI C/O REALTY EXECUTIVES
Date of Inspection: 5/15/01
SITE EXAM
_Slope
_Surface water
_Check cellar
Shallow wells
Estimated depth to ground water 12+feet
Please indicate(check)all methods used to determine the high ground water elevation:
NO Obtained from system design plans on record-If checked,date of design plan reviewed:n/a
NO Observed site(abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board of Health-explain: n/a
NO Checked with local excavators, installers-(attach documentation)
YES Accessed USGS database-explain: n/a
You must describe how you established the high ground water elevation:
USGS MAPS AND CHARTS- 12+FEET
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11
C0tiIMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF E?�tiIRON\IE�TAL AFFAIRS
- DEPARTMENT OF ENVIRONMENTAL PROTECTION .
IM W ONE WINTER STREET. BOSTON. ktA 02106 617-_5:-5:C'G
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Lt.Govcmor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FO oF� r� 6) J"
PART A r B�F
� A CERTIFICATION
Address of Owner: "Soln,rvS .,/
Property Address;
Date of Inspection: Of different)
Name of Inspector: '
am a DEP ap roved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name:/ � a crTr' E� r� �"�'� roc P
Mailing Address: 2O A COP32?-4 /�f}�></�P�' � �� 42-C&q
Telephone Number: r:57 ti2t-2 �j-�9" 44
CERTIFICATION STATEMENT
I centf that I have personally inspected the sewage d:sposa' system at this address and that the information reported, be!oN' is true. accurate
and comolete as of the time of inspecoo The inspection was performed base= on my training and experience in the proper function and
maintenance of on-stte sewage disposa: System,. The h•stem. :
Passes
Concit.onaii% Passes
_ Neec: Furtne- Eva!uatlon Sy the Local .Approving Autnont\
_ Fa
Inspector's Signature.
_ 19
Date:
Tate Svste^ 1ns.eco• sha!' submit a copy of this inspecoon report to the Approving Authorir\- within thim' (30) days of completing this
inspection. If(he system is a shared systern o• has a design flow of 10,000 gx or greater, the inspector and the system owner shad submit
the repo-, to the appropriate regional office of the Depacment of Environmenta' Protector.. The orig:na! should be sent to the system ownf
and copies :-n:to the bu%•er, ii applicable, and the approving authority.
INSPECTION SUMMARY: Check A, B, C, or D:
AI SYSTEM PASSES:
1 have not found any information which indicates that the system vioiates any of the failure criteria as defined in 310 CMR 15.30=
Any failure criteria not evaluated are indicated below.
COMMENTS:
BI SYSTEM CONDITIONALLY PASSES:
One or more system components as described in the 'Conditional Pass' section need to be replaced or repaired. The system, ups
completion of the replacement or repair, as approved by the Board of Health, will pass.
Indicate yes, no, or not determined (Y, N. or NDi. 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 (201 years prior to the date of the. inspection;
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or ex(iltration, or tar
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
w approved by the Board of Health.
fr■ •:.•c' 04/2!')7) P■ce 1 of 10
+ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .... .
PART
CERTIFICATION (continued) - -
-i' =��- .. - - .._ tom`: . ..._ �' .1 - ..':; `..- _ _ ,,;i17:"ryt,:i.•
Property Adde4ss:
Owner: .�.i..• r. ..,^'i.7
Date of Inspection:
Bi SYSTEM CONDITIONALLY PASSES icontinj,!�d'
Sewage backup or breakout or high static water level observed in the distribu on box is due to broken or obstructed
pipets) or due to a broken, settled or uneven distribution box. The system 11 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 brok n or obstructed pipets). The system will pass
inspection if(with approval of the Board of Health):
broken pipetsi are replaces
obstruction is removed
CJ FURTHER EVALUATION 15 REQUIRED BY THE BOARD OF HEALTH: -
Conditions exist which require furthe•evaluation by the Board of Heal in order to determine if the iystern is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES T AT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AN THE ENVIRONMENT:
Cesspool or prn-, is within 50 fee, of a surface water
Cesspool or pri%N- is within 50 feet o:a bordering veg led wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAI
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PRO ECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption ystem (SAS) and the SAS is within 100 feet to a surface water supply ar
tributary to a surface water supply.
The system has a septic tank and soil absorptio system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorpti n system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorpt' n system and the SAS is less than•. 100 fee, but 50 feet or more from a
private water supply well, uniess a well wat r anaiysis for coliform bacteria and volatile organic compounds indicates tha
the well is frep from pollution from that ('ac' ity and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method used to determi distance (approximation not valid).
3) _.OTHER
(revised 04:25/9') page 2 of 30
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SL_'BSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIOI FORM
PART A
CERTIFICATION (continued)
Property Address: '
Owner:
Date of Inspection:
DI SYSTEM FAILS:
You must indicate either -Yes` or `No" as to each of the following:
I have determined that the system violates one or more of the following failure criteria a< 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.
Start hauad leyei in the distnbition box above outlet invert due to an overloaded or clogged 5°.5 or cesspoo!
Liquid depth in cesspool is less than 6- below invert or available volume is less than 1/2 day floe.
Reouired pumping more Char. 4 times in the last year NOT due to clogged or obstructea pipe's .
Number o-*times pumped _.
Any portion of the Sod Absorption Svstem, cesspool or pnv)- is below the high groundwater eieyatior
An,. por::on o:a cesspool or pri%-�• is w•ithir. 100 feet of a surface water supply or tributar to a surface water supply
Any porion of a cesspoo' or prwv is w ithin a Zone I of a public well.
An% pc—io- e:a cesspool or pri%1• is within 50 feet of a private water supple well
Any por,.orr o:a cesspool or privy is less than 100 feet but greater than 50 fee: from a private water supply well with no
arceo;able water quart\ analvsis. If the well has been analyzed to be acceptable. attach copy of well water analysis for
cohiorm bacteria volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E] URGE SYSTEM FAILS:
You must indicate either `Yes` or "No- as to each of the following.
The iolio%%mg criteria aop;% to :urge systems in addition to the criteria above:
The system serves a facilm with a design flow of 10,000 gpd or greater (Large System; and the system is a significant threat to
public hea!th and safes and the environment because one or more of the following conditions exist.
Yes No .
the system is within 400 feat 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 an), such system shall bring the system and facility into full compliance with the groundwater.treatment _program .
requirements .of 314 CN1R.5.00 and 6.00. Please consult the local regional office of the Department for.-further.informat ion_-- - _ ..__.__.-•-
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: � �
Prop J
Owner:TN bbZx
Date of Inspection:bt Z41
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 recently or
as pan of this inspection.
— As built plans have been ootained and examined. Note if they are not available with N A.
— The facaha or dwelling was inspected for signs o'sewage back-up.
X — The s,,•stem does not receive non-sanitary or industrial waste flow.
The site %%as inspected for signs of breakout.
— All svSierr. co-nponent:. excludine the Sod Aosorption System, have been located on the site. r
— The septic tank manhoies were uncovered. opened. and the interior of the septic tank was inspected iar condition of
banies or tees. matena; o' construction. dimensions, deptn of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption Svstem on the site has been determined based on
X — The fac,la, o%%ne• .ano occupants. is dtfteren-. trom ow•nert were provided with information on the proper maintenance of
`T Sub-Suriace Disposal Svstem.
— Existing information. Ea Plan at B.O H.
— De;ermined to the field uu am of the failure criteria related to Pan C,is at issue, approximation of distance is
���CCC unacceo:abie 115.302:3t:blt
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR-M
PART C
22 SYSTEM INFORMATION
Propert% Address: `JS S�n►s PVEii,3
Owner:TOOQas,
Date of Ihspectlon: blzLkkc�
FLOW CONDITIONS
RESIDENTIAL:
Design flow .p.d..bedroom io:
Number of beorooms
Number o:current residents
Garbage g der (yes or no!:_
Laundry cor—ected to system (yes or no!
Seasonal use (yes or no!:-
Water meter readings. if available (last two f2: year usage tgpd(: t
Sump Pump (ves or no(•�
La<-. da:e o.occupanc-,—
COMMERC7 kl-1NDUSTRIAL:
Type of establishment
Design fio%% ga!tonsida%
Grease trap present ryes or no_
Indus:nal \taste Holding Tani: Dresen, aver or no
':on-santta,% Haste d,scnarge, to the T!:te 5 system ives or no_
X%ater meter readings if availabie
Las:pave o: o
OTHER: .De:cribe
Last sate of occuoa-ic.
GENERAL INFORMATION
PUMPING RECORDS and source of tnforr�atior.
N� QQW\Q��
System pumped as par, of inspeGion: wes or no._
If yes, volume pumped gallons
Reason for pumping
TYPE,OF SYSTEM
Septic tank/distribution boxisoll absorption system
Single cesspool
Overflow cesspool 1
Piny
Shared system (yes or no) (if yes, attach previous inspection records, if any)
I/A Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date Installed (if known) and source of information: —IL)� `�a
Sewage odors detected when arriving at the site. (yes or no) ='
(r.•iud 0�/2S/7�1 Pay. 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTESA INFORMATION (continued)
Property Address:
Owner:;71A JQS
Date of Inspection:
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 Ire
Diameter
Comments: (condition of joints, venting. evidence of leakage, etc.)
SEPTIC TANK:
(locate on site plan
Depth below grade-
material of construction- 4oncre:e _me-.a _Fioerglass _Polyethylene _othertexplain
If tan' is metal, list age _ Is age con:irmec o,. Ce^.fica-e o: Compliance _(l es.-No
Dimensions (000 0l W'
Sludge depth- 3 1
Distance from top o: sluoee to borzo-n o' out;e: tee o• ba;-;;e
Scum thickness- au _
Distance from top of scum to top of outle: tee or ba-';.e
Distance from bosom of scurn to bo-o--: o;outte: tee c- ba*:.e
How dimensions were determined
Comments
trecommendation for pumping. rondition o� inlet and outlet tees or baffles. depth of liquid level in relation to outlet invert, struct ral
integrity, evidence of leakage. e:c.i tv^ eomd 0-t I \ � U1
w'
GREASE TRAP:��
(locate on site plan;
Depth below grade:
Material of construction: _concrete _metal Fiberglass _Polyethylene —other(explain)
Dimensions: -
Scum thickness: - - -
Distance from top of scum to top of outlet tee or baffle. - -
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping: _
Comments:
--'"(recommendation for pumping. -condition of iailet and outlet tees or baffles, depth of liquid level in relation-to-outlet-invert,-structur-al-
integrity, evidence of leakage, etc.,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
e
�YSTEM INFORMATION (continued)
Propertm Address C 3 P01 tV
ON ner:- Lt pbtlIS
Date of Inspection:/ I C,
TIGHT OR HOLDING TANK:#Jb --Tank must be pumped prior to, or at time, of inspection,
(locate on site plan,
Depth below grade.
Material of construction _concrete _metal _Fiberglass _Polyethylene _other(explain)
Dimensions:
Capacity gallons
Deng^ floN galions.da.
Alarm level Alarm in %:orking orde• _Yes. _ No
Date of previous pumping
Comments
(condition of inlet tee. condition o- a!a•r. and float switches. etc.)
DISTRIBUTION BOX:W'S
(locate on site p;an
De.:h o;liouid lee•. aoo,e oucie: in.e': G7V'a�`u•�UU�lC.1
Cornment5
to to :i tel and des:nb oc i aua' of $olids carnov e��dence of leakag into or out of boa, etc.)
v tic...
PUMP CHAMBER:_4L-kV
(locate on site plan.
Pumps in working order: (Yes or No'
Alarms in working order (Yes or No.
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Propertti Addr-ss: *M nail
Owner-T-Ibb Crrs
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS):l �
(locate on site-plan, if possible; exca%atlon not required. but may be approximated by non-intrusive methocisi
If not determined to be present, explain:
Type: jv�X�
leaching pits. number.
leaching chambers, number:_
leaching galleries, number:
leaching trenches. number,tength:
leaching fields, number, ci,menslons
overflow cesspool, number
Alternative system
name of Tecr,notog-v
Comments
to to condition of soil, s!grs of hydraulic failure, leve' of ponding. ndkton f ve atlon, etc., ,� C,
CESSPOOLS: �A
(locate on site play.
Numbe• and conflgura:,o::
Depth-top of liquid to inlet ,nver,
Depth of solids lave--
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of ground\,vate-
inflow tcesspool must oe pumpec as par, of inspection,
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:_L5 -•-..
(locate on site plan)
Materials of construction:
Depth of solids: Dimensions:
Comments
_.._
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): -
04125/97) n.y. 8 or 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
m SYSTEM INFORMATION (continuedi
Propert} Address: l 3S S 1oSe.'A' VIk1 NT
O%ner.Tbbc TS
Date of Inspection:`
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
.2r—
2
0 0
Q 3
a�,y,,
.. a 91
Qt t� r e � �
EY34t .
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Propertv Address• SRVjr'-`� Cotter
Owner:� [CS
Date of Inspecuun: r ILU I�
1P l tl
Depth to Groundwater �� Feet
Please indicate all the methods used to determine High Groundwater Elevation:
yObtained from Design Plans on record
Observation of Site (Abutting property. observation hole, basement sump etc.)
Determine It from local conditions
Check with loca! Board o• nea!tr
Check FEMA Maps
Check pumping records
Check local excavato,s installers
l_•se IL SCS Da:a
4
r•
Desciibe in vou, o%%-. r-oras r.o,.% %o" established the High Groundwater Elevation. (Must be comple{led!
� 1�,W �1naw�S � w �- r \ (o 1 Iba tTa`'"• ° t—
VIT- NT
lrevu•d 04;25'9'. Page 10 of 10
i
TOWN OF BARNSTABLE .
LOCATION L.$° /t'� STo ►�.y ft?b SEWAGE #SG- I L
VILLAGE < ASSESSOR'S MAP 6z LOT3..)z_ '1
INSTALLER'S NAME & PHONE NO Am m4wrel
SEPTIC TANK CAPACITY ��00• 10A
LEACHING FACILITY:(type) #I SO# UP (size) 69(a
NO•..OF BEDROOMS3PRIVATE WELL OR PUBLIC WATER -W
BUILDER OR OWNER —TACAe T/220 X
DATE::PERMIT ISSUED: (o G _ k?
DATE .COUPLIANCE ISSUED' cp I�
VARIANCE GRANTED: Yes No
iR
ON
:a
h._..h yzy. -:.1 pr.0 fi ,h •�� .."��' .V.,. y�1 .:;a.� wsti,
TOWN OF BARNSTABLE
LOCATION��'y` /��. �'@ d �/Pt?b SEWAGE #86 I L
VILLAGE -ReQru ST L ASSESSOR'S MAP & LOT 03D
INSTALLER'S NAME & PHONE NO. ..7lfS 4 Aj
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) o6a �®• (size) 6A
NO. OF BEDROOMS 3 PRIVATE WELL OR PUBLIC WATER -W
BUILDER OR OWNER
DATE PERMIT ISSUED: (o rS
DATE .COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
► S) e o F �-(ous� .;
2e�
' � 1
Lo
—&A R N STV R4 6'•
4SSESSORS MAP NO: -�36
9 CEL NO.- 32
�� � Fus...................��.....
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
T w o...........OF......
�s ,9.........................
Appliration fur DwpotiFal 3Varkii Tonotrurtion Frrutft
Application is hereby made for a Permit to Construct (L,,j or Repair ( ) an Individual Sewage Disposal
System
�tat:
.---
Location-Address or Lot No.
s---•------------------------------------- ......B -STD}81.�..---•-•-•-------•--•--------•--•------••---.....----
Owner Address
a � ,"A i��� .��`^�-----Ln.c-•-: `�`•°°�•-----•- -•-t�---Q-a---Pirzx...1.6.Q_ Yar�.n u th _D.r_t:- Ma..-----
Installer Address
Q Type of Building 3 Size Lot...
f.2�1--------Sq. feet f
U 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..............33�...................gallons.
P4 Septic Tank—Liquid capacity_/P;?..gallons Length..g.6b_•._ Width._ "!�.... Diameter................ Depili.- T."'..
Disposal Trench—No.-------------------- Width................:... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No-------/........... Diameter.__...�O/._..... Depth below inlet......6_1...._... Total leaching area._T�7_....sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by._.ill-v✓ ? ....L.... !/.............. Date...1,e......
aTest Pit No. Z...4-_-4:.._.minutes per inch Depth of Test Pit___/7_1f_.-`�_ Depth to ground water........................
(i, Test Pit No.a...G.L._minutes per inch Depth of Test Pit....Lt.�------ Depth to ground water........................
W ---••-•---••-----------•--•-------•••-•--•••-•-•.............•-•-------......................------...----------------------••--...............•-•--...--•--
O Description of Soil.......- .........L�/Do Lo„9-,-I� .Sc� -Soil-__
� .._•-•�74....•---_�cA2�s�.•..SA a �••-�'.e.9-,/��
W
VNature of Repairs or Alterations—Answer when applicable.......................__' S�SG11Ili� __Ed�16a1P+61=I=1:i i�lLt _ .............
'tiSTA4 !4T1� .. T SUPERVISE:
•----------------------------------•--------------------•--•------------------=------•----•-----------------•-•------------------------------ A+�i€)--�i:�Tfl=1f'I�J WRITING
Agreement: THE�SYSTEM WAS INS
TAL�ED II�,f$TRICT
The undersigned agrees to install the afor edescribed Individual Sewage Disp k�CB ice i ,Raccor ante i
the provisions of 1 TLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the b and f health. ,o
� �
Application Approved B} �Cd. ....................•----------......----- -•-•-•...J-•`qatI_��....
Date
Application Disapproved for the following reasons:....................... ......... ... . ......... ...................................................
_
..............••----•-----••-•----•---------•---------------•--•-----------------.....-•----...-•- •........................ ...........__. --- ---------- ......2............................
Date
Permit No ....1.--2- �- ............ �---•--....
Date
No --------- Fps............._............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............�..�..t(/.....-.....0F.......�1 /.ST.! ;/3G...........................................
Appliration for Uh4paii l Workii Tontitrurfion Prrutit
Application is hereby made for a Permit to Construct L,-) or Repair ( ) an Individual Sewage Disposal
System at:
+y— Location-Address or Lot No.
._._..-- ------------•----' t""Ili--r•-•-7-------•---•----_^.-•- -----
owa /� `l t Address
alac......(-----•--------- ..... sax...16.Q.,...�ar_mou_thgart•....?"ta..-----
InstaLer Address
UType of Building 3 Size Lot_.G f_ .........Sq. feet 2'
�--� 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..............dQ.._........._...__gal_. Ions.
Gd Septic Tank—Liquid capacity/P�?5?...gallons Length.g_ ...... Width."/_ Diameter................ Depth-.`a",e......
Disposal Trench—NTo. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No-------I_......... Diameter-----i4?.......... Depth below inlet.....G........... Total leaching area_Z!�7.._...sq. tt.
Z Other Distribution box ( ) Dosing tank ( )
0-4 Percolation Test Results Performed by._L:.T�_! ..... :___.�-� ��/ ......_.... Date-�!a•7�•_•Z�-.��8�.....
Test Pit No.2..4-__4r.....minutes per inch Depth of Test Pit-_-�7!&".. Depth to ground water----------°'_.____--__-.
4q Test Pit No.3--- _........minutes per inch Depth of Test Pit...lj� ...... Depth to ground water..__"'".............
-•-•--------------------•---•------•-•-•------•--- --...•••-•------'................__.._-•'-..._..._..__.........----••-•••-----•----....._......----------
D Description of Soil....... .•,-.<��_"_------In/009 '5c �3-Sv,� 4� CL.9Y
x / 17411
7A --------------
U ......................��....../FY-��.....-•�......2S C~....r•?.."lw�....-....... ......._....•......................-.
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 TTL -5 of the State Sanitary Code— The undersigned 'further agrees not to place the system in
operation until a Certificate of Compliance has been issued
e —� 7
b3 6.. aFrLfht
_........--• --...................................1/�, , ---/f ./..�_� te
Application Approved BY '�
-•------------•--•----•---•........................
.�......_
Date
Application Disapproved for the following reasons:.......... ... ....... ...... ....................................................
•-•-•--•------------•------...--••-•-•...................................•-----------•---....•--- -------------• ---- -----••---• .............................
C� 1 -2 � `(
-
Permit No.-----.----'....................................... ued....---
Date
.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD pOF HEALTH
...............<..c�.�!V✓.1..........OF.......GJ!'5 ZIV-5-74e64-!— .:.....
klyrtifirate of Tomplinnrr
THIS h et Individual Sewage Disposal System constructed (WOT or Repaired ( }
by---------- .................... ....... ---•-----.................--•--•-----.........._.......---•--'•----------
- - -v
B
C> .r- Ins
at........................................................---- q --------- --------�-------- ------------------------------•-------------------
.�::::}
has been installed in accordance � ith the provisions of TI of The.. tqr Sanitary Code s d c the
CSC P 1"7 -1 ��f '�'
application for Disposal �G'ons Construction Permit No......................................... dated--------------- -....__.._•_...__..._._-__.....
TIME ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT YHE
SYSTEM WILL F CTION SATISFACTORY.
DATE
................ ........'' Inspector...-G�
`'= .
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
12 -w'` ........OF.. zH/S -/ '..................
PTO...._.... •--"-•- FEE........................
3pt1�1 �[� tton lerutt hole 3v!dla"cic
Permission is hereby granted.........................Camme.t.t....C.On s xx tic t i nn.....I n-.c.........
to Construct r Re 'r an ndivi ual Sev�a e.-D•i al S em
03
atNo. _i ti. ../ .................Street....................................................... 1'...-•--
as shown on the application for Disposal Works Construction Permit N0........... _��'lhate
....................... ` ..� '-••_i�.{_�-�— .....................
Board,Board,of Health
DATE................................................................................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
r�-
SO4/4�T w7? ,lg
ti•
TOP OF FOUNDATION
— , CONCRETE COVER
CONCRETE COVERS
4' CAST IRON 12"MAX. ° 12"MAX. •
OR SCHEDULE 40 4"SCHEDULE 40 PV.C.(ONLY)
P.V.C. PIPE
PITCH I/4"PER. PIPE- MIN. LEACH
PITCH 1/4"PER.FT PIT PRECAST
NVERT � °. a ..�••
LEACH I N G
EL.?.!`c-`�... INVERT INVERT p� W e:� PIT OR
SEPTIC TANK DI ST.
ELLS./B . EL. B.So >__ EQUIV.
a INVERT BOX
��d4. .. GAL. INVERT
o' EL.Z9.3S. yyq INVERT ww a: :'�• 3/4"TO IV2'
�a \ :;; WAS
o , w STONE
WDIA.
PROR LE OF GROUND WATER TABLE
SEWAGE DISPOSAL SYSTEM N__�- 4z& GNSv�TgigLE'
�'}T�TL9L //V 77ye-
NO SCALE �x}cs/ .9�TE "q- z>
YD 86-
w/rH c4e>q'�'
SOI L LOG WITNESSED BY :
DATE /M4 TIME. //.=�' !�'? D`?!�s !'�'. �v . BOARD OF HEALTH
TEST HOLE Q TEST HOLE 3le%�I7Er`--/• ENGIN EER
ELEV. . .3.Z.Go ELEV. ..37.zo, .
DESIGN DATA :
NUMBER OF BEDROOMS
TOTAL ESTIMATED FLOW . .3d . . . GALLONS/DAY
7B,5o
BOTTOM LEACHING AREA SQ.FT. /PIT/L;p P.
Zo,zv SIDE LEACHING AREA . . .� '�v , . SQ.FT./ PIT147/CAA
Cv'q?z�e GARBAGE DISPOSAL ./A/v '�(50% AREA INCREASE) .
C2Av�zs soqwDTOTAL LEACHING AREA . . ZG7 a v. SQ.FT
�, 2� PERCOLATION RATES 7��N Tlt/o MIN/INCH
� /�4 rL. /8,/0 19 Z Ez zo . . . .
Nd. .WATER ENCOUNTERED LEACHING AREA PER PERCOLATION RATE .' 77(:U . SQ.FT/CPD•
NUMBER OF LEACHING PITS
APPROVED . .. . . . . . . . . . . BOARD OF HEALTH W177/ ,7y(/o -&-2- S7'D^/4r a Al
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
DATE. . . . . . . . . . . . . .
AGENT OR INSPECTOR
va�Pv1N 0cz
Ga T�/3 EDwID G`�� rj
a
E �' �
v LLEY 'n
26100kN sr�P�
�.
PETITIONER : � • -S.
,
j
1
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avid
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IrA*J IN,
� ,� of r��. � ,:� .•
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DESIGNING ENGINEER MUST SUPERVIS'.":
,» NSTALLATION AND CERTIFY IN WRITINra o ''KELLEY
�liM.�-t+��c•/17 �`1.9 S. ";-!F SYSTEM WAS INSTALLED IN STR�G(" �\ No. 26100 �o
-• Pr�ri+r To PLAN. a ,�n Ew
fr '�� "�'fCISTER��fy
3
3''•'AL L,p{t�
r