HomeMy WebLinkAbout0046 MILLSTONE WAY - Health 46 MILLSTONE WAX 089-714
UPC 12543
No..�....5 R cor+s'4
HASTINGS,UN
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
o-c- L /a
Property Address
ner Qv ner's Name ,/
requhWfo is Ce✓r-�-e✓v, Ile 14 da G 3� ��
requlredforevery
page. Cly(Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
f"P01 out for '1e" A. General Information
f on
out forms
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not IS e, -
use the return Na me of Inspector r
. Company Name
Company Address
Clyfrown 1 r, State Zip Code
og d8o -
Telephone Number license Number
B. Certification
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 16.340 of
Title 5(310 CM 16.000). The system:
Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
rl
Inspecto's Signature ate
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 god or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DER The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
""This report only aescribes 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. 1 t�
1/0�J
t9m,Y13 Tile SOHldallnspecdcnForm suftoacese*%eolspoeel Symm-Faye 10,17 `V
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Y& All
Property Address
GtS an�
ON ner Om nees Nam
information Is
required for every
page. aty/Town State Zip Code Date ton
B. Certification (corn.)
Inspection Summary: Check A,B,C,D or E 1 always complete all of Section D
A) =und
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:
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.
Check the box for'yres!I "no'or"not determined"(Y, N, ND) for the following statements. Knot
determined,"please exdain.
Ir
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound, exhibits subslantial infiltration or exfiitration or tank failure is imminent. System will pass
Inspection if the existinb tank is replaced with a complying septic tank as approved by the Board of
Health. '
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance Indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
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Commonwealth of Massachusetts
Tide 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Property Address
owner ON s blame � v` /� ��
information �G 3�>s
requiredforevery Ctyfrown state Zip Code Date k�s tbn
B. Certification (coat.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes(cont.):
Obseh static
level in the distribution box due
❑ o broken or obstructon of ed pipe(s)or duet a brok backup or break out or en, settled or ueneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
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
16.303(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 sail marsh
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fire•W3
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
L�6 ���t� tAla
Property Address '
Oar ner ON nee$Name
�uk*d for every —6e&1 (/l
page. Oty/Town State Zip Code Del of Inspection
B. Certification (conL)
2. System will fail unless the Board of Health (and Public Water Supplier,if any)
determines that the system Is functioning in a manner that protects the public health,
safety and environment:
❑ The system has aseptic tank and sal absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must
be attached to this form.
3. Other.
D) System Failure Criteria Applicable to All Systems:
You ni=Indicate "Yes" or"No" to each of the following for al inspections:
Yes No
❑ Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ �/' Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ �/' tatic liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ Liquid depth in cesspool Is less than 6'below invert or availaafe volume Is fes$
_ than' day flow
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form'.Not for Voluntary Assessments
1 c,./a
Properly Address
aS ��
Ow nor ON ner's Name /
Infonration
ed fcr is
Ceo�e✓yt` ��
page. City/Town State Zip Code Date cx m0ection
B. Certification (cony
Yes N;��Required
❑ pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ Er,-' Any portion of cesspool or privy is within 100 feet of a surface water supply or
/ tributary to a surface water supply.
❑ [�' Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ Cif' ��Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ 2 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 IDEP certified
laboratory, for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than S ppm,
provided that no other failure criteria are triggered A copy of the analysis
and chain of custody must be attached to this form.]
❑ The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ The system ftU . I have determined that one or more of the above failure
criteria exist as described in 310 CM R 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.
L) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 16,000 gpd.
For large systems, you must indicate either*yes"or'no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area— IWPA)or a mapped Zone II of a public water supply well
9 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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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface sewage Disposal System Form •Not for Voluntary Assessments
Property Address /
Owner Ow nees Name �^
Information is Ge N ✓v``� �� Uol 6 4) J 0115
required. for every Qyfrown state-" Zip Code Date of nspecti
e
C. Checklist
Check if the following have been done. You must indicate'yes*or'no"as to each of the following:
Yes o
❑ umping information was provided by the owner, occupant, or Board of Health
❑ ere any of the system components pumped out in the previous two weeks?
C] s the system received normal flows in the previous two week period?
❑ Have large volumes of water been introduced to the system recently or as part of
this inspection?
Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
Was the facility or dwelling inspected for signs of sewage back up?
Was the site inspected for signs of break out?
Were all system components, excluding the SAS, located on site?
❑ Were the septic tank manholes uncovered, opened, and the Interior of the tank
Inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
Was the facility owner(and occupants if different from owner)provided with
Information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
Existing information. For example, a plan at the Board of Health.
❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)1310 CMR 15.302(5)1
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): Number of bedrooms (actual): --�-----
1-f770
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
•�' Title 50MON Impectlon F OM SUbSUlaN Sewage Dlapoeal SYWM•Poge 6 of 17
Commonweafth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
L� A/1 rL-f
Property Address /-
�S
ON nor
Innforrnation to CW ner'S Nome
required for every
page. CdyfTown State Zip Code Dat of lrlspecdon
D. System Information
Description: C �soo `��,� �'��-t y f✓
Number of current residents:
Does residence have a garbage grinder? ❑ Yes L'7" No
Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes lJ'N
o
Information in this report.)
es 9-19F
Laundry system inspected? ❑ Y Yes
Seasonal use? ❑ LINO
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
Sump pump? ❑ Yes No
Last date of occupancy: Date
Commercial/industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CM R 15.203): Gallons per day(gpd) ---
Basis of design flow(seats/persons/sq.ft., etc):
Grease trap present? ❑ Yes D No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Mee 5OWN"POMn F arm Subswaoe Sewage Dlspow System•Page 7 o117
mrn•ans
Commonwealth of Massachusetts
Title 5 official Inspection Form
sments
Subsurface Sewage Disposal System Form-Not for Voluntary Asses
Rroperty Address /a
A S 6v►✓
oN Her aN Hers Herne AU da6 3d- Jr' !/
infom�atlon is �e /�c_-- --
upage edforevery City/Town w / Sta— to zip Code Det of Inspectbn
D. System Information (cunt.)
Last date of occupancy/use: Date
Other(describe below):
General information
Pumping Records:
3 f
Source of information:
Was system pumped as par
t of the inspection? ❑ Yes
Ifyes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of Sy .
Se pt
is 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/Altemative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system�e owner) a copy of latest
inspection of the VA system by system operator
act
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
1'iao 5ofWd ktspa:W Form 6upeufaoe 69wape01epoW SYmm-Page 8of 17
Ore•3M3
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
GS .aw�
OW net ON ner's Nameinfo n IsI JJ Alrequ�orevey Cleo 4y'l l!� / 3� j
page. Cdy/Town State Zip Code Date petition
D. System Information (coat.)
Approximate age of all components, date ins Iled (if known)and source of information:
Were sewage odors detected when arriving at the site? ❑ Yes M No
Building Sewer(locate on site plan): /
Depth below grade: feet
Material of construction:
Elcast iron 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below gra e: feet
Materi construction:
concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
a
Sludge depth:
firm,3H 3 Tise 5 oMdd inspeclan F orm Subswwe Sewage Dispoad System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Lf 6 A/IAr4-f--
Property Address
Qv ner Cw ner's Nam / �j
information is Ceoje"'6 � /� 4 o d_
requiredforevery Cfly/Town State Zip Code of specton
D. System Information (corn.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle � —
How were dimensions determined?
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
u✓h r n .l�o� ✓�cP�
-/'%.f f I
Grease Trap (locate on site plan):
Depth below grade: feet
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: we
Ore-3M3 Tile50r0oi fropeclon Form SubMIKO SOWNSDleposd Syakm•Pape W d 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Property Address
/261
ON nor ner's Nam /
Information is C2✓ fe✓lic /4 �-
required for every
page. Ckyfrown State Zip Code Mao knoection
D. System Information (coat.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow. gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in worldng order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
'Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
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f
Commonwealth of Massachusetts
TjTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
11,r4yze— LA/4
R'operty Address
as ��
Oar ner ow ner's Name /� j
information is
required f or every Rowe State Zip Code �e,Of n
page. �Y
D. System Information (cono
Distribution Box (f present must be opened)(locate on site plan) �
Depth of liquid level above outlet invert
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.): /
d �J
Pump Chamber(locate on site plan):
Pumps in working order
❑ Yes ❑ No"
Alarms in working order. [I Yes ❑ No'
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
" If pumps or alarms are not In working order, system is a conditions] pass.
Soil Absorption System (SAS) gocate on site plan, excavation not required):
If SAS not located, explain why:
Tile50MCiei trppeotlMFomc Suowrfwe SevrageCiepoW S)om Page 12 Q V
tans•Y13
Z\ Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage /
Disposal System Form -JNot for Voluntary Assessments
Ll
Pmperty Address
Cw nor AN noes m®
Inforrrrequir lfodon to evr ►�!// Ae- (�( ��
required for every
page. City/Town State Zip code Date OflnspecW
D. System Infor lion (cont.) /� _ car j
Type: ��b l,✓ �f�e _
S
leaching pits a number:
❑ leaching chambers number.
❑ leaching galleries number.
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number.
❑ innovative/altematire system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
ova 1n
V ✓/f 07Z— �/Aw k c C
Cesspools(cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface sewage Disposal System Form -/Not for Voluntary Assessments
6 Ally � („/'a
operty Address
ON ner ON nees NameWorm �j� !� 1
required tion
is C2,4►1-y6Ile-, 11114 a6
requ'vedforevery
page. Cilyfrown State Zip Code Date py ins n
D. System Information (cont)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of constniction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
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f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Addressr
Af
Oar nor s Name f
information Is / 2� /�,4
required for every 1,
S
Page. Cky/Town tate zip Code [ate b�S
peCtfon
D. System Information (coat.)
Sketch of Sewage al System: Provide a view of the sewage disposal system, including ties to
at least two anent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
ttttin
er Supply enters the building. Check one of the boxes below:the area below
❑ drawing attached separately
Q
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i n L
iz xfl-✓S
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T1ne80MdW WpecknFarm SubwAns Sewepo01opmd SWOM Pape 15 d 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage
/Disposal System Form-Not for Voluntary Assessments
UV
party Address
S �e_
Owner ON nets M� A'Vk
Informadon Is C.'o `/,t C Z2
requhW for every
page, Ctyrrown State Zip Code Dane ift Inspectiaon
D. System Information (cost.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water. feet 10
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
Isd� Checked with local Board of Health-explain:
,
❑ Checked with local excavators, installers -(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
4v l`—
4//
S� S !s X 8,110 �,� �►
Before filing this inspection Report, please see Report Completeness Checldist on next page.
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for voluntary Assessments
141,`ls c,�
Address
. �S d✓ TC..�
��evey ON ner"s Nan„e C2w ✓/ /'�%� ( 7oZ S �i/i3
PW Cilyfrown "' rQ DO RN
r
E. Report Completeness Checklist
a Inspection Summary: A, B, C, D, or E checked
F
Summary D(System Failure Criteria Applicable to All Systems)completed
rmation—Estimated depth to high groundwater
Sewage Disposal System either drawn on page 15 or attached in separate Ale
n
On -3113 TW*50Hdsl lapeCOMF«m bbO Soe SWOWDWPGW$YOM-Pepe O d t7
L�(p TOWN OF BARNSTABLE
LOCATION Lg T /'/i /S%d/�!L al.4l SEWAGE
VILLAGE('- ,�w?r 2 v/l�`� ASSESSOR'S MAP 6i LOT
INSTALLER'S NAME & PHONE NO., ZGh
SEPTIC TANK CAPACITY/ SMGO G,09/
LEACHING FACILITY:(type) c CBfT T.s (size) JL/�
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER/U/e_
BUILDER OR OWNER FEZ P A-' Af RA 5'P6A/7-L=
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED: / f/
VARIANCE GRANTED: Yes- No �/
AIS GSA y
3� 33
7
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f:! • f
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
...... ...TOWN..............OF BARNSTABi �----------------------..._.....------------------
5 Applirotion for %np000l Workg Tonotrnrtion Prrutit
Application is hereby made for a Permit to Construct ( X) or Repair ( ) an Individual Sewage Disposal
System at:
......A. q1_ Millstone Way---•-••--------------------•--.... One
�J...... - • .. ..... ....
L tion-Address LaZ!Ta".o'anff- or Lot No.
Richard fa an c�o Frank Raspante,_65 Millstone Way,
. .................._._.. ..........�---------._....--•---•-•..._..._.... • ••--........ ..._...........!•-----•--
Owner Address
W Centervile,MA 02632
. ............................ .........
i Installer Address
Type of Building Size Lot..... l!.220_........Sq. feet
Dwelling—No. of I Bedrooms.......Three Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
dOther fixtures ---------------------------------•-------------------....------------------------------. ----•----•-••----•--•••--•-•-•............•-•..............•-
Design Flow.............................................gallons per person per day. Total dais , flow...............3.0..__.... .......•..._gallons.
W Septic Tank—Liquid capacity.1500 gallons Length._10 6" Width.._5 o-��..._ Diameter._._- ._..._. Depth..5'4"
x Disposal Trench—No. .........:......... Width•...�. Total Length................1.... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.._.........__..__. Depth below inlet........._...•.._.. Total leaching area..266,30..sq. ft.
Z Other Distribution box (X ) Dosing tank ( )
0-4 Percolation Test Results Performed by.......B.S.C. GROUP&APE COD,INC..•••- Date..Dec•.-.•19,],9$$.........P-7227
Test Pit No. l......__ ?.._minutes per inch Depth of Test Pit 12 Depth to ground water
f=, Test Pit No. 2........
._?._minutes per inch Depth of Test Pit__.....12....... Depth to ground water-------- ...........
----•-------------------------------••-•••••..-•-:-•-•••-•...---•--....._......-•----------•............................................................
O Description of Soil_...__1)__0 - 24" Top and subsoil,24" - 144" Medium sand with s cobbles.
----------•......- -
x 2) 0 24" Top and subsoil,24" 144" Medium sand with some••cobbles.V •------------------------------------
UW --------•--------•--------•--•--------------------------------------•-•--------------------•---------------•--------._...--------- ------------ •--17
Nature of Repairs or Alterations—Answer when a licable-_f .... - ----_ _ __-_---- ._..? _. _ ..._..
•• .................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
LipT�'1'�•
the provisions of 'T i t 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 board of health.
Signed...................................................................................... •..............................
Date
Application Approved By.......... %"__...... _. titi,__
Date
Application Disapproved for the following reasons-----------------------------•--•-----------------------•------------------.....................................
.........••••----••-•-•-••••••---....••••..........-•----••••-----••-•••--------•-••...............••-----•-••--••-••-----•-----•-•---•••--------•-•--••••------------••-•----.........................
�7 Date
��Permit No.---- ._:.....�!_�_X_-- ----.-•--••-- -------
--------•--•----•------• Issued---------------•----
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
' .....................................OF........J,
f
ApplirFa#ion for Diupuoal Works Cnoustrnrtion 'pumit
+ Application is hereby made for a Permit to Construct ( X) or Repair ( ) an Individual Sewage Disposal'+
r System at:
One Millstone Warr On
........................................ ...........-"•---------..._....--- ......--
L tion Address Lactmo and or �o.
......................Richard-• aY --••-----•--•---------'-'•-•--•-••----•- _clo l:`rank Rae an e�_b�5 Millstone_Wayr._
1.u.�.
W Owner Conte.vile♦MA 026
L�ress \\
Installer Address -•------- --------- -----•---
Type of Building Three Size Lot-----——�Z�.-_•-____Sq. feet
Dwelling—No. of Bedrooms........................................... Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
P4 Other fixtures .................................................. . _ .....
er
ly
Destgc Tank—Li uid ca aci 1500 allons Per personth1P0�6p Y�dthl �1$„ �Diameter 330--.--_. Depth_dons.
r4n
W P q T PY g 10�� ►g P
xDisposal Trench—N.. .................,_. Width.................... Total Length...............11.... Total leaching area....................sq. ft.
Seepage Pit No._._._.:_.-.l-._... Diameter...........--...... Depth below inlet__........R._.__.. Total leaching area_.2F�e.9Q.sq. ft.
ZOther Distribution box (X ) Dosing tank ( )
Percolation Test Results Performed by.......PAW G�ROUP�CAPE..C':ADiINC...... Date..Dect...19t.19$6-------_P-7227
raj Test Pit No. 1...:...�_�..minutes?...minutes per inch Depth of Test Pit_--..-_1.2V_.___. Depth to ground water..--_..-"-........--..
a w Test Pit No. 2...._. per inch Depth of Test Pit.......la�__._.. Depth to ground water..... ................
O Description of Soil.....1).-- - 24" To and subsoil►.24" 144 Medium sand wifipl 0�901@__001�b1A1l.
0 .- 24" Top-&nd eubsoil,24"- 144", Medium sand-with some c6bbles
v --••-----•-----
` :�:.
UW -----------------------•----••------......•-•-------------------•--•------------•-••-••-----••-••••---------------------------------•----------•--••-••••----•............---=--•---•...................
Nature of Repairs or Alterations—Answer when applicable................................................................................4:•_
Agreement:
` The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of i T T Lip 5 of the State Sanitary Code— The undersigned further agrees not to place the systein in
r operation until a Certificate of Compliance has been issued by the board of health.
Signed...................................................................................... ..................I........
_....
Date
Application Approved BY < ..�,�.k w:�----.-----•--------•-•-•----• , = -` �
Date
APPlication Disapproved for the following reasons:--• ----•------••-•---•----••---•-----•-------------------------••-•---•----•----------•---••--•••......._...--
PermitNo..... .-.....7 j-----------------=------ Issued-------------------------------------------------
L:.'
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.............. OM......I..........O F............BARNSTABLIr.............._..........................................................
Cwrrtifiratr of f ompliFaatre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed � or Repaired ( )
by•...............••••-•---•-••--•-••-•-••-•--•-••••-•-•---------'--•-•---•-•-•......--•--•.....•--....•••••••-••------••..................._......-••-•------•-•---............•-•-•-•-•-••......--
r �A / Installer
at----•--- -----� .....<•......... 1,,1- _411� _- w - ---
has been installed in accordance with the provisions of 11Z 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.._.___ S" -_'___-7JAy_.... dated..._............................:.....'.......
THE ISSUANCE OF THIS CERTIFICATE, SHALT. NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.'
DATE----... .......................... Inspector_-..--
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TC7WN oF............BAiRN�TABLE
Q L .................................... .......................... `'�
NO.A2 7l , FEE. .......
Diuposatl Workii Tono#rnr#ion �eruti
Permissionis hereby granted........................................................................................................................................ ....
to Construct (�f or Repair ( ) an. Individual Sewage Disposal System
at No.........J--a.7--•--4---•---- 1--i_�.(._ ------------- s�k:� �.- s �.........................................
Screet
as shown on the application for Disposal Works Construct nte!% No. r�'-q L
1 %�/ Dd
I oard of Health
DATE......... ' .................................. i
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS
-f - - - - - _ - - - - -
6-U-1-L D E-R-S-1J-I�I.A E- -A D-D R- -SS
D ATE-RE R-NA- T 1_SSU
4elAveorie-,
+ e
W
No.... ........... �J
THE COMMONWEALTH OF MASSACHUSETTS_
BOAR® OF HEALTH, ;.
-._. ... ... OF.............................................................. .....................
Appliratiun -for Ii,4 ulial lVarkii Tontitrurtinn Vanift
Application is hereby made for a Permit to Construct (� or Repair ( ) an Individual Sewage Disposal
�i System at: r
+ ' � / -�➢� �---------------------------4---------------------------------------
Lo�ccation-tiddress k / or Lot No.
.(,_l). 10...tE , ----- ---... . ..... i4 ��'-.
ner _ ........................... Address
W �
staller Address
U. Type of Building Size Lot_AX,7A0.....Sq. feet
a Dwelling kNo. of Bedrooms�� _____________________________Expansion Attic ( ) Garbage Grinder ( )
Other—T1 e of BuildingAUL No, of persons___________________________ Showers Cafeteria ( )
0.' Other fixtures -•---------------------------- c�
W Design Flow.................... Sf_.__...._. gallons per person per day. Total daily flow___-----�1_- -- •-------- --------------gallons.
9 Septic Tank Liquid capacityr, - gallons Length................ Width._____...__.. Diameter----- Depth-.-__--._.__...
-x Disposal Trench—No_ __________________ Width.... __ Tot Len ........ Total leaching area--------------------sq. ft.
Seepage Pit No..____- .__. Diameter..[ __` elow mle ______._. Total a area______ _ ____ _ _sci. It.
Z Other Distribution box ( ) Dosing tank ( ) t;Z- C — - ����• .�t
Percolation Test Results Performed by-------------------- -•-•--------------------------------------•---------- Date----------------------------------------
W
Test Pit No. 1----------------minutes per inch Depth of "Pest Pit.................... Depth to ground water-_____-______.___..---
1:1q Test Pit No. 2................minutes per inch Depth of Test Pitt.................. Depth to ground water----------------------
---(.-----
O -
�.. ` = _. <
- --- ----- -----
Description of Soil
-------------------------------47----------- ---------------------------------------------------------------------- ------------------------------------------------- --
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 Article XI of the State Sanitary Code The undersigned further agrees not to place the.system in
operation until a Certificate of Compliance has bee issued by the board,of- lth.
Signed.... ''.... 11 ' d ------------------•------------
Application Approved B .. Date/
�ddrb Date
Application Disapproved for the following reasons------------------------------------- ----------------------------------------------------------------------
..-•--•--••---•-•--•-•...-•••------••....•-------------------•------•-----•-------•----------•-----------------•------•--•.............-•------------ ------------------------------------------------
Date
Permit No......................................................... Issued----... .....
- Date ...... ...:... ...•--••.
PermitNo......................................................... issued...................... .................................
a o-; Date t
THE COMMONWEALTH OF MASSACHU:SETTS "' 4-,
BOARD OF HEALTH
' nTrr#if ira#le of f �autli�tnre
T IS IS TO,CERT T e Individual Swage Disposal System constructed (�)•or Repaired ( , )
by..... ----------- ----
nstaller
at.. I
` has been installed in accordance wi the provisions of Articl XI of The'State Sanitary Cos d cribed to the
application for Disposal Works Construction P,erffi, No...._.._.�_-I..... •-----.-•-• dated ...~... l�' �.. ...
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSY D AS A GU' APITEE THAT THE
?•` SYSTEM V+IILL FU CTIVTFACTORY.
.�=
DATL........... ... Inspector '`'+_:
.
`y THE.COMMONW,�ALTH OF MASSACHUSETTS.•
I
- � BOAR-D OF HEALT {/J�/• - -
OF..
FEE.._
rl 1rk� �n r at rrrti#
Permission 's reby granted._. •----- , ;`
to Construct ( or Repair ( ndividual Sewage D/ V-
..os 1 Syste
r
at'No. . 'uG� ! Y� d 14-�1 � '. .["` ,
Street 1s
as shown on4e application for Disposal Works Construction Per. 't No: Dated.....Z/�f �I
_? 7Yr!i/f'�. `..
t n 1. �: •_ ..Board of Health �e ..........................
r'.....
rDATE... ..l�.o . ..-7 `
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS D/S • .\ ,,... f�. / ,
� 3 ;7��," J . I VVV 11 � _ / .Y`` f '•L..
' ice'THE COMMONWEALTH OF MASSACHUSETTS Y
BOARD OF .HEALTH
.................• -:....----
Appliration -for Ditipofial Workii C omitrurtion Prrmit
Application is hereby made for a Permit to Construct O or Repair ( )- an Individual Sewage Disposal
System at:
Location-Address or Lot No.
/_E? •r�•'
•1 ner Address
f
-. a a
p istaller Address
Y
Type of Building Size Lot_J,0..7K .....Sq. feet .
f f.- DwellingkNo. of Bedrooms--._ -3-_______________________________Expansion Attic ( ) Garbage Grinder ( )
—Type of Buildin
•,, ''.° rgk�• �.. No. o'tpersons.........................'. Showers ( f — Cafeteria ( )Other
Other, fixtures ------------------------------- -------- ----
W Design Flow--_____._:..•_-:_-_ . �.._...__._77 gallons per person p� day. Total daily flow........... __gallons. .
WSeptic "1'.�nk�Liquid capacitvPVg lions Length............ , Width_.___.... __.. Diameter......... ...... Depth.
x Disposal Trench—No. ........ ....... Width_......._ .. To en � _ Total leaching area_---.::---__. sq. ft`
Seepage Pit No.._..-„ :.... Diameter__ _ l elow le ... .... ..... Total�acni area..-_. sc�. ft.
Z Other-Distribution box ( ) '�- Dosing tank ( ) � � G "` '!!d/,�y �t
~" Percolation Test Results Performed by------------------------------------- - -
,.a ,
- -- -------------------------------- Date............------------------------
Test Pit-,No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water-----------__..:--------
Test Pit No. 2................rninutes per inch Depth. of Test Pit p::............. Depth to ground wa"ter...........................
{Yi _---•-------------------
'- f
Description of Soil f'." d tt ` r ` """T� .................... -----------------
x
W _____________ __ __ ________ _________________ ___-_-__-_________---.-_--_•-•-----__-_---•_._-.------_-_----.--_-_---__------- ----. -. --___-_ -____--___- t
U Nature of Repairs or Alterations Answer when applicable ______________________________ -_-.-._.--'._--. _-
' ------------= -------- -------------------------=------------------------------ -- - - - ---- -----------------------. ---- ---------
Agreement: -
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with :e
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees notf to.placo the,-system in
operation until a Certificate of Compliance hasAbbeeissued by the board of h lthSigned. - Qf .I - -•-----------
. D/teeApplication Approved By..... 'lff T �1..... '�
Date.
Application Disapproved for the following reasons:--------------•---------------- ' .................................................. ...................
a .
•-•••---••---•--••-- ----------------------------------------------------------------------------------
Date
i
3
r
®,4 -.
ti
1
i
,..� _J i' APPLICATION FOR PEROOLATION TEST AND OBSERVATION PITS
L(SCAI4ON NO. 7�-�-
`VLAGB �'d .DATE
APPLICANT_ SE- (f FEE _'��
n ..A�.
ADDRESS 4 , t TELEPHONE NO. -7/e/ (Non-refundable)
ENGINEfi$._ S G TELEPHONE NO. 1?7�•25z�"
DATB.SC iBUU LBD cl t e6 J/
a: (Applicant's Signature)
: .. .... .. .................................................................................................................................
ASSE wSSOR"S MAP 6 LOT NO:
µh Z51 / Got ,Ale. /6'G SOIL LOG
SUB-DIVISION NAME DATE Lbv TIME /I�*� ANJ
EXPANSION AREA:.YES NO _ C� �S� 69-'v? `���`61> LAC. ENGINEER
TOWN,WATER PRIVATE WELL BOARD OF HEALTH
_4N ywx 41A/_5lz,/r_7yA✓ EXCAVATOR
SKETgH: .(Street name, etc., dimensions of lot,.exact location of test holes nn.d percolation tests, .
locate wetlands In proximity to test holes)
NOTES:
300
140 No wcn�iNb rtJ PppmrrY
4-:
30' T P .4-L Go T N0, .156
OLATION RATE: TLbQ'
HOLE NO: '' I ELEVATION: TEST HOLE NO: 2- ELEVATION•
2,4
2 TOP t 5vG ou_ 2 la _ ; S-j8501 C_
4 4
5 5 P3PC-Tgir ;
6 µ�lu{� SANT) 'W, SoNE CoMW) 6
7.
7 yiND u�( S»�6 GcrdP,u3"�
e 9
9
. 10 10
NO WR t 11 11 IJo W AZ_
12 12
13 13
14 14 / -
15 15 r
16 `• 16
ABLE FOR SUB-SURFACE SLWAGE: LEACHING FIELD LEACHING PITS
LEACHING TRENCHES'
ITABLE FOR SUB-:SURFACE SEWAGE. REASONS:_ Gevb GCC1�o�1 pp � �6n52/k, - ACAOSi
GR.kv�t - Pen�c. D1l rc � 2- No` N0 w 1'n�- I-L
ENGINEERING FLANS MUST SHOW NUMBER ASSIGNED ON PERC TEST APPLICATION
INAL: COMPLETED IN ENTIRETX BY P. E. AND RETURNED TO BOARD OF HEALTH
RETAINED BY APPLICANT •�
SAIL L0G
l N 0, 1 EL.�4. 0 EL.C2.8 N 0 2
. SITE PLANToPsa/L I 7D~1[ 0
� I
SddsO/L EL.G2.3 2 E[,Ga.P SdBSO/L.
4
MED/UM
TOP OF FOUNDATION EL.. 66.0o S�.uo 6 w,rfl
••a W/Tf/ SOME
• � SOME 6
G08BL ES
2/ FINED GRA
�JS OE 9
7, I N EL / 1 0
.,.� IN t� G29 IW t� ci/z MIN. COVER If
IJ
4- y ._ 2 COVER 1/8 3/8 WASHED STONE ., .�L.sas /\/o rvATE.e I
G/•L4 � . � o � dVGodN7f��.
?: i ft f l G/.47 c o ° , ,• a :• • ' f No ;v,4z6e
:p IN EL:�B� •. ,. ° • • tl • 3/4 1 1/2 WASHED STONE 1y E,vCo�/NTE�Eo
UI B W/ 6 SUMP0110
13
4' LIQUID LEVEL .. o : o ° ° 14
6, E F F ° • ` ,
11 . V � - -a-�T'-T°r--�`° " ° ' • ° : DEPTH " . ° ° ° P E R C T E S T RESULTS
PRECAST SEPTIC TANK WITH •4 • ' ° • ° PRECAST LEACHING PITS NERC RATE : ZM/N• PFR /n/CH•
CAST IN PLACE INLET AND El.s¢'8o • : •. • , o °. a •o/vE • c•���.►�i r6' ECTivL- t WITNESSED BY Duvv/N� I
NO.. ---. SIZE.
I. OUTLET T S PER TIT LE V I / / BARn/STHBL� gpARD OF HEALTH
SIZE : /moo G A L L O N S DIA '
� Z 6 z OF STONE DATE : DEC. i9, i9B8
t �a.6•' LONG , x sa` W 10 E x s'4" D E E P 1 4 Pervious /O /DIA ALL AROUND �E�Foe/r/tL2 ay asc ��P-e19P ' co
G o,AVe-
Materia 7Z27
E L. IrZ
I 1
BOTTOM 7L-5T P/T
I
I, , s ss• /o /6� E
PROFILE OF PROPOSED SEWA- GE SYSTEM
1 Z47
SYSTEM DESIGNED BY THE TOWN OF _ ,aARiySTABL� REGULATIONS AND ---
I SCAIf : 1/4' 10
I ; STATE TITLE V FOR SUBSURFACE DISPOSAL OF SEWAGE °
Sf. SG
°
N ¢a I I B
— . I I I I c P •. I Q•
I 1 . ALL PIPES SHALL BE SCHEDULE 40 P.V.C . SEWER PIPE , T [_ � ,
2, ALL PIPES SHAM BE SLOPED 1/4 " PER FOOT EXCEPT FOR
•w I I I ' ' ' ' ' ' 6 .4 1 ^ i
T FIRST 2 FEET OUT OF THE 0 /8 WHICH SHALL BE LEVEL sQ `,
HE , I I ► I I
3. DESIGN FLOW .3 BEDROOMS AT 110 GALDAY PER BR . 3_ GAL/ DAY
6Z/.S
SEPTIC TANK SIZE .�.330 X.. = ___. GAL I i
49s II
', � i I I t / PiCoA�SEl� .3 BED.�ODivJ f
USE /soo GAL. W/ ayT GARBAGE DISPOSAL - WDOdEN �wE�L,i✓lr, �\
LEACHING SYSTEM : USE ' '
G' /AM• %Y r.' EFF6GT/VE DEPTH P,e�GAST Lc��I,Ch//it/!r /�/T ; ; i i N TOP FOUN!)fl7/o/\/EL.
W�Z OF W.95//LGI> STD,c/E �9,e0/1/VD. V i I i i i I zt /4' zz
EFFECTIVE AREA : S 10 E zrr-,eh x Z.s=zrrk sx X za= 471
B0TT.0 . • 0 1 I I ;u3
M 7Ti4t X /0 = Tl X ZS X /•O= 7B•S G•P b-
I TOTAL FLOW 4;71 -r7es = s49• sG.P.D, i ; I 3�• ,�, \
\ I
.
TOTAL REQ D FLOW 330 X is s3o W/� GARBAGE DISPOSAL ILIA
�.
RESERUE FLOW .¢9s — 3so �:2/9.s GAL/ O�Y - IN RESERVE
• � i so s1 58'�i /G' 33"
Po�.E
4E f8 sf rc . 63-1�4 — —lt- -------
Co GLE[\;E �Y/ST/N� P9✓�sYIENT
I
,
R E F E R E N C E P L A N S T
AATL=a \Tstn/u�FeY• ./9c9• �.8• � 66vc�//rlAxr I
PLA/� 8�,< Z28 PEE APPROVED BY : �Eo��T`yo �3¢
- _ BOARD Of HEALTH
DATE : ANDSEWA E PLA
PROPERT �' OWNER ; �icyARb ���r•�-»,� ASITE _ AGE
e,,/o RASPA-/ti/T _ �N of sP
- N of �qss P` "''ss9 FOR
R
cS M/LLSToW--- WAY
—,—� j®Hf4 9`yG � ROBERT oyc 3 BEDROOM SINGLE FAMILY DWELLING
CEWTE�ViLLE, MASS. a2�3Z � P. � N
z M. m
1 / DOYLE,ICY N DAVIDSON L 0 T ONE /�I/[[STo/uE Wfl Y
No.33sss .0 No. 24500 �� I 0 A r E . /VaV�ML3E,P 27, /989
lq�FGISTER��p� (o vF O.�FcisNATLEN D YLE ENGINE E R ING ASSOCIATES, INCORPORATED
'+, Box u 13' - 530 Thomas B. Landers Road W. Falmouth, MA 02574