390 Title 5 Application/Permits 1992, Inspection 1996 PROPOSED DOMESTIC SUBSURFACE DISPOSAL SYSTEM DESIGN
Prepared For:
Location:
Number of Bedrooms:
G.-eV N/ac r
L• )` 4 I N.r/+t Fi0rint Rood , Al 'Term.
4
Garbage Disposal:
LEACH AREA DESIGN
Bedrooms x 2 persons/bedroom = 8 persons
£i{ Persons x 55 gallons of wastewater/person/day = 49'O total gallons of
wastewater/day.
Percolation Rate: (i • Pl min/inch
Gallon of wastewater/square feet of leach area for a Percolation Rate of:
6, - 8 min/inch = /• 440 Gal/SF Sidewall Area
=
C.617 Gal/SF Bottom Area
* If a leach bed is to be installed, no sidewall is allowed.
* If percolation rate exceeds 20 min/inch, no bottom area is allowed.
- SEPTIC TANK -
ALAI F.R
* WITHOUT GARBAGE DISPOSAL:
Gallons of wastewater/day x 150% =
capacity of septic tank.
RECOMMENDED: Septic Tank
REQUIRED effective liquid
* In no case will the septic tank be less than 1,000 gallons (effective liquid capacity)
** WITH GARBAGE DISPOSAL:
441(7 Gallons of wastewater/day x 200% = 880 REQUIRED effective liquid
capacity of septic tank.
RECOMMENDED: /.SOO Septic Tank
** In no case will the septic tank be less than 1,500 gallons (effective liquid capacity
FICNTE & ASSOC/A-IRS. INC:.
LEACHING PIT DESIGN
Precast Pit Used: _120.2 Long x $ ' Wide x 2 ' Effective Depth
Using 4 ' of stone all around and 2S " of stone under pit.
SIDEWALL AREA:
le ' Long x i.tS' Effective Depth x 2 Sides = BI SF
I'S ' Wide x 2. Lf ' Effective Depth x 2 Sides = .S8 •C SF
Total of 139• S SF (Sidewall Area) x 1 .4(O Gal/SF = 2-037 Gal/Pit (Sidewall)
BOTTOM AREA:
_ S ' Long x 13 ' Wide = t34 SF
2,344 SF (Bottom Area) x O.(.7 Gal/SF = 1 St .8 Gal/Pit (Bottom)
2.0 3 . 7 Gal/Pit (Sidewall)
/ f .. Q Gal/Pit (Bottom)
3(.O .S TOTAL Gal/Pit (Designed)
* Without Garbage Disposal: Total Gal/Day (REQUIRED)
* With Garbage Disposal: 1.5 x 44/ 011 0 Gal/Pit
0 Gal/Day (Daily Flow) = (REQUIRED)
Usin g 6GO Gal/Day (Daily Flow) $ 254,0- 1-254,0- 1— Gal/Pit = Z Pit(s)
.AL\IER HU VI LEY. JR.. & ASSOCIATES. INC.
Resonr
coceeers
Der sea
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4
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sra'JEt 2'TNC
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E /.0 4ccoenek^E W/TH THE 574 TE EN✓/RON%-✓ENTAL
.PE TNAU aVE SCEPAC,E O/T OP ODPY WELL A.PE M/
GRE4TE57 EFFECT/YE IV/07.41 OA DEPTN OF THE
,tMTE' ' CODE - TinttES LLB/
•zSSda /9 TO CBE 7W/CE THE
P/T, WH/CHEYER /D
GRE4 TER.
ALMER HUNTLEY, JR. a ASSOCIATES , INC.
REGISTERED LAND SJR ✓EtORS L Ci✓IL ENGINEERS
125 PLEASANT STREET
n1noTUnVOTON . MASS .
Wllllam F.Weld
Mover
Arq•o Paul Cwllueel
LLB,
Commonwealth of Massachusetts
Executive Officepf Environmental Affairs
Department of
Environmental Pro
4 SUBSURFACE SEWAGE DISPOSAL SYS
PART A
J IL S F-r FZ L CERTIFICATION
'L 0 t taa c Property Address 3 r O N /}ri was YL fl
Date of Inspection: % / V r 9 C Address of Owner.
Name of Inspector. --CD /f 1`e /} L 1./ S ❑t different)
Company Name,Address and Telephone Number. 3 Z l 3 6,
L I_. f i ,)-P J O a,o re `
fS' / 6 7-t /z_ 5 '7— L ✓ 0 L. OW o / CSC
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 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:
17 Passes
_ Conditionally Paces
_ Needs Further Evaluation By the Local Approving Authority
_ Fails
2 3 '&a
Trudy Cosa
unwary
yid B. Strung
Commasereee
Inspectors Signal
7/ l6 / c 6 Date:
`12...,.,, 7/ / [ / 11
The System Inspector shall submit a copy of inspection report to the Approving Authority within thirty(30)days of completing this
Rspection.I r
the system is a shad system or has•design flow of 10,000 gpd or greater,the inspector and the system owner shall submit 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:
Chet° B, C, or I):
A] SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 910 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 iaSltration or exliltratio"
imminent. The system will n,ere is to tank as is
Pass inspection if the existing septic tank u replaced with a pod'ormipg septic talc u apprrved
by the Board of Health.
(revised 11/03/95) 1
One Winter SEW • Boston,Maaaschusetta 02108 • FM(617)556-1049 • T lephone(617)292-6600
Cl Posed on Recycled Paw
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address 3 9 O N . Fri- 2 F+t /2 /) .
Owner Q Iti 5 N f� L. L
Date of Inspection: '7 / / I / 9 C-
/31 SYSTEM CONDITIONALLY PASSES (continued)
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipes)
or 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)an 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 pip(.). 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:
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.
Cesspool or privy is within 50 feat of a surface water
Cesspool or privy is within 60 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:
3) OTHER
The system has a septic tank and soil absorption system and 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 is within a Zone I 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 lees than 100 feet but 50 feet or more from a
supply well,unless a well water analysis for colVmm bacteria and volatile private lls free
from pollution from that facility and the and nitrate compounds indicates alt tort the well is free
Presence of ammonia nitrogen and titnte niteoganv equal to or lees than 5 ppm.
(revised 11/03/95) 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address 3 9 o N F /l 2 rvt
Owner.
Date of Inspection V fi 5 L L
D] SYSTEM FAILS:
2 /3
_— I have determined that the system violates one or more of the following failure criteria as defined in 310 CIO 15.303. The basis for
this determination is identified below. The Board of Health should be contacted to determine what will be newesary to correct the
failure.
Backup of sewage into facility or system component due to an overloaded or dogged SAS or cesspool.
Discharge or pending of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is bus than S"below invert or available volume is len than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipets).
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 L within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of•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 legs than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well ham 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 in addition to the criteria above:
The system servos•facility with a design flow of 10,000 gpd or greater(Lugs System)and the system fait significant threat to public
health and safety and the environment because one or more of the following conditions mist:
the system is within 400 feet of•surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system L located in•uitrogan sensitive area(Interim Wellhead Protection Area(IWPA)or•mapped Zone II of•public
water supply well)
The owner or operator of any such system shall bring the system and facility into Ml compliance with the
requirements of 314 CMR 5.00 and 6.00. Plea.consult the local regional office of the De p h r orrtet onetmeat program
gioval Department for Father imformitwm
(revised 11/03/95) 5
Property Addrnc
Owner.
Date of Inspection
SUBISURTACE SEWADE DISPOSAL SYSTEM INSPECTION FORM
PART B
CRECRLIST
3 4 12 A, r2-°
/ / G / ci C
Check if the following have ben done:
✓Pumping information cues requested of the owner, occupant, and Board of Health.
Novo of the system component,have ben 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 part of this inspe ion.
AS bulls plans have been obtained and examined. Note if they are not available with N/A
u,..
facility or dwelling was inspected!ate signs of sewage bask-op.
y/f/�hhe system dote not receive nonce or industrial waste flow
_L/Tho site was inspected for signs of btaalmyt.
AB system component., excluding the So S,,A?orption 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.
A,/Phs size and location of the Soil Abeorptlon System on the site has been determined based on misting information or
approximated by non-Intrusive methods.
321The facility owner(and occupants,if different from owner) were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 11/03/95)
1
Property Address;
Owner.
Date of Inspection
81n3PWW41215 S$y4GE A7yPOSAL SYSTEM INSPECT/ FORM
PART C
SYSTEM INFORMATION
3 q ° hi
& LJ I -5 rte L C.
-7 / iG / 9 /
no-
FLOW CONDITIONS
ES
Design fbw: tL SaaLons
Number of beyoomr rr�t
Number of anent tridents `L
Garbage grinder(yea or no):SS
Laundry connected to system(yr or no): $
Seasonal use(yes or no): NO
Water meter readings,if available: rr 1 Y 4 r-✓) cflt. / /O
1
Lam data of oeapancy;_j/r5
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow: Wilonwday
Grasse trap present: (yes or no)_,
Industrial Waste Holding Tank present: (yes or no)
Non-aanitary weste discharged to the Title 5
systems (yes or no)_
Water muter
readings,)[available:
Last date of occupancy
OTHER (Describe)
Last date of occupancy:
PUMPING RECORDS and puree of information:
GENERAL INFORMATION
1 9 9 2 o LA ,,_,.q.2
System pumped as part of inspection:(yes or no)S5
If yea volume pumped: /O O o gallons
Ramon for pumpinr 5 C V p n 6Lq-/�Uy
TYPE GE SYSTEM
t/ Septic tanWdistnbutiov hos/soi abmrption system ..
Single oessPOOI
__ Overflow cesspool
Pricy
--Shand system(yes or no) (if yes,attach previous inspection snooty,if any)
Other(explain)
APPROXIMATE AGE of all components,data installed(if imown)and source of information
Sewage odor detected when arriving at the she:(yes or no) fr'O
(revised 11/03/95)
5
/992
c '(t
r ) ac_ /9
0 LA-, et_
SUBSI}BPACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART
SYSTEM INFORMATION(continued)
Property Addreec 3 44 o ni f6 Pi-/L-/'t/ a-12.
Owner: ' j. s ' L
Date of Inspection:
—7 / / 6 / 9?
SEPTIC TANK
(locate on sit*plan)
/m rf
Depth below graft: %
Material of construction:JZioncrete_metal_FRP_other(cplain)
Dimansione: l O O D a—J..1 t r1 ,i t Z% ,
Sludge depth: Lj i7
Distance from top of sludge to bottom of outlet tee or baffle: c g
V
Scum thickness C
Distance from top of cum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle: /y /
Comments:
(recommendation for pumping condition of inlet and outlet tees or baffles, depth of liquid level in Nation to outlet invert,structural integrity,
evidence of leakage, em.) �u m /J 2 pG /� G / c c7 -r- i_ I1 T .a./IF-/c/ F
/ Fz V / p Lc ' T�+ ev 1c / y N /5= /<
GREASE TRAP:_
(locate on site plan)
Depth below grade:_
Material of construction_concrete_metal_PRP_other(explain)
Dimensions:
Scum thiclmra:_
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,spycnny)
evidence of leakage,Stn) integrity,
(revised 11/03/95)
6
nal9ODaVAOE SEWAGE DISPQBAL SYSTEM INSPECTION FORM
PARTC
SYSTEM INFOIIMATION(continued)
Property Addrew: 3 9 0 N . ,C p9 /2/'ti n
Owner.
Date of Inspection: 7/ / ` I L
TIGHT OR HOLDING TANK_
(locate on Nits plan)
Depth below grade:_
Materiel of construction: =mete_metal FRP_other(eaplain)
Dimensions:
Capacity: endow
Design Dow: aallonsiday
Alarm level:
Comments:
(condition of inlet tee,condition of alarm and Coat switches, etc.)
DISTRIBUTION BOX_
(locate on site plan)
Depth of liquid level above outlet invert: 0
Comments:
(note if level'and distrlbntinn is equal,evidence of solids carryover,evidence of leakap into or out of tco,etc.)
/svr L— D /s7 (g-- ! /SO7-1c /Q fl uirk-rL
At / sir nY • t' / /r n./` d 6— i /3 (2S
PUMP CHAMBER:_
(locate on sits plan)
Pump in working order:(yes or no)_
Comments:
(note condition of pump chamber,condition of pumps and appurtenances,etc.)
(revised 11/03/95) 7
Property Addspr
Owner.
Date of Inspection:
SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM
.). PART C _
SYSTEM INFORMATION(continued)
3 q o N , rVI K ry /2 /9
N c L L
/9
SOIL ABSORPTION SYSTEM (SASh
(locate on n4 Ple".S possible;avavation not required,but may be approximated by non-intrusive methods)
If not determined to be present,explain:
leaching pits,number:_
leaching nbambera number:
leeching galleries,number.
leaching trenches,numberlsngth: 8
leaching&Ids,number, dimensions:
overflow cesspool, number_
2 f-/ >c LC o
qeo sq et-
4
Comments: (note condition of w4 signs of hydraulic failure,level of ppooading,condition of vegetationetc.)
/ / n H-v n /1 / () B—/(
if V f')la nap/ "sat./ 6 -y
CESSPOOLS:
(locate on site plan)
Number and oonflgmation:
Depth-tap of liquid to inlet invert:
Depth of solids layer
Depth of sc m 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 condition of
pending, vegetation,etc.)
PRIVY:
(locate on site plan)
Materials of construction;
Depth of solids: Dinuuaims:
Comments: (note coodkio,of eo0,signs of bTiraulle fathtre,level of ponding,=ion of vegetation,etc.)
(revised 11/0.3/95) 8
SURSUH Afl SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address .3 '1 6 A/- / -/'3-/L /t, /2 g
Owner. V .)L 5 f%.i I t .L L
Data of Inspection 7 1 6 / 9 6
SKETCH OF SEWAGE DISPOSAL SYSTEM;
include ties to at Last two permanent reference.Lndnuuks or benchmarks
locate all wells within 100'
}V f /2.,i fl o.
DEPTH TO GROUNDWATER
Depth to giouodweter. fr
method of determination of apptodmadoa jUt L) 724.-/ft /3 % ^
5L-a / ezi / P3C /4 2gn,/a_
(revised 11/03/95)
9
CFIECK OR FILL IN WHERE APPLICABLE
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Lti of Nor}hatnphN (floreAcc_
) pplirntion for finponal 11Jorkg Tnnntrnrtinn der
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual
System at:
390.__N aleuris £D... Lr a z-,
or Lo No.
6 west $ ' Nt�if.4te.93µIEV
Location•Address
O.V.S4 P..n?..._4WO-SIJ iiL
putt -lrt re tf5�ei �
Type of Building
Address
411141[-may n •
Address
Size Lot 37, V3 Sq. feet
Dwelling—No. of Bedrooms 3 Expansion Attic (Al) Garbage Grinder ( As)
Other—Type of Building tC5 No. of persons Showers ( ) — Cafeteria ( )
Other fixtures
Design Flow SS
gallons per person per day. Total daily flow SZe gallons.
Septic Ta,-rt,;p ry"',quid capacity fW�+ gallons Length_10t t Width .111FA Diameter - Depth 48 p
Disposal T-TEXe3i, No I Width 2-It Total Length 510 I Total leaching area 41 0 sq. ft.
Seepage Pit No Diameter Depth bel w inlet Total leaching area sq. ft.
Other Distribution box (4 ) Dosing tank (N) %iJ Sisk- ENc' ca..,S . e / /
Percolation Test Results Performed by _AA4/es5. Q.S. Date Se1.dl Z
Test Pit No. I 10 minutes per inch Depth of Test Pit.. .( _a2" Depth to ground water 4 t
Test Pit No 2 minutes per inch Depth of Test Pit Depth to ground water
Description of Soil Bazz..■med F rwa — mat. 5n'a till.. s f_Y.:W (s'.n0.le 5 _.. a$__
5+0(0 05. ) S.I.t.LNTC V C nPAc T
Natur of Rep{�rs or Alterations—Answer when applicable NPSf
_el Agreemc
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance 1 been issued , the boar health.
L. 13eY, replo e_ S LTANc
Application Approved By
Application Disapproved for the following n
Permit No.
77/(71 '--
Issued
THE COMMONWEALTH OF MASSACHUSETTS
/� - BOARD / TH
��t1i/ f O/F H/Ei G 'fl
OF
ertifirufe of Criomplittnce
TH 7'0 CERTLEY, That-the Lndi iidnal Sewage Disposal System constructed ( ) or Repaired (X )
39G Aeirr 471, I fRil
i:
at
has been installed in accordance with the provisions of TITLE 5.m )Tlya$tare Environmental Code as described in
the application for Disposal Works Construction Permit No. d--f i. 1}_, dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED ALA GU RANIELTB,T THE
SYSTEM WI ISF�CTO
DATE _.._. Inspector _.
3 L
THE COMMONWEALTH OF MASSACHUSETTS
` BOARD OF HEALTH / The
—1 i -, OF. .itr.'.Let-St..P----1 ,_—f'-C"^-- FEE
No.,,r..i� U
3ispru nl Cf orb Otrnj trurttIIn lrrInit
Permission is hereby ranted 44. h 4/ C^+
to Construct ( ) or Re/pair) an Individual Sewage Disposal System
`
at No 3 -..
as shown on the application for Disposal Works Construction Pefrfi;t 10, L--. . Date
l.L.
Board of H earth
L
t, c
DATE / > /
"�. �1..-'(�.
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS