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HomeMy WebLinkAbout0019 MIZZENTOP LANE - Health T-1 9 Mizzentop Lane Centerville F/R A = 227 069 UPC 10259 NO.H1630R NASTINOS. MN 1 1 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ; 19 Mizzentop Lane " Property Address M� Allen Mulligan _ Owner Owner's Name -' information is required for every Centerville / Ma 02632 6-7-18 ' page. City/Town State Zip Code Date of Inspection „} Inspection results must be submitted on this form. Inspection forms may not be altered ini'any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information 0 on the computer, use only the tab 1. Inspector: key to move your cursor-do not Brett Hickey use the return key. Name of Inspector B&B Excavation _ r� Company Name 374 Route 130 Company Address Sandwich _ Ma 02563 City/Town State Zip Code (508)477-0653 S113747 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 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority -jr -- A 6-7-18 Inspector's Signature Date 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 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.. ""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. 00 t5ins•3/13 " tie 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 19 Mizzentop Lane Property Address Allen Mulligan Owner Owner's Name information is required for every Centerville Ma 02632 6-7-18 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 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: System was in working order at the time of inspection. 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"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. 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. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 19 Mizzentop Lane Property Address Allen Mulligan Owner Owner's Name information is required for every Centerville Ma 02632 6-7-18 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ 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 ❑ 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 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 19 Mizzentop Lane Property Address Allen Mulligan Owner Owner's Name information is required for every Centerville Ma 02632 6-7-18 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 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: ** 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 must indicate"Yes" or"No"to each of the following for all 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 ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 19 Mizzentop Lane Property Address Allen Mulligan Owner Owner's Name information is required for every Centerville Ma 02632 6-7-18 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® 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. ❑ ® 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. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [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 ' 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 fails. 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. 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 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. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 19 Mizzentop Lane Property Address Allen Mulligan Owner Owner's Name information is required for every Centerville Ma 02632 6-7-18 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has 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) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 2 Number of bedrooms (Actual) _2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 352/GPD t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 19 Mizzentop Lane Property Address Allen Mulligan Owner Owner's Name information is required for every Centerville Ma 02632 6-7-18 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d See below 9 ( Y 9 (gP ))� Detail: 2016-61,000gallons 2017-27,000 allons Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: NA Design flow(based on 310 CMR 15.203): cations per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.).- Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 19 Mizzentop Lane Property Address Allen Mulligan Owner Owner's Name information is required for every Centerville Ma 02632 6-7-18 page. CityFrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Owner- last pumped 2-2016 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® 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) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments �^M 19 Mizzentop Lane Property Address Allen Mulligan Owner Owner's Name information is required for every Centerville Ma 02632 6-7-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 2003 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ® cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line. Town feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: 1 feet Material of 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: 1500gallons Sludge depth: 4 t5ins-3/13 Title 5 Official Inspection Form.Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments CGM , 19 Mizzentop Lane Property Address Allen Mulligan Owner Owner's Name information is Centerville Ma 02632 6-7-18 required for every page. CityTrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 32 Scum thickness 0" Distance from top of scum to top of outlet tee or baffle NS Distance from bottom of scum to bottom of outlet tee or baffle NS 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.): Tank was in working order at time of inspection with liquid level equal to outlet invert. Tank is in need of pumping at this time and should be pumped every two years for maintenance. Grease Trap (locate on site plan): Depth below grade: NA 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: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 19 Mizzentop Lane Property Address Allen Mulligan Owner Owner's Name information is required for every Centerville Ma 02632 6-7-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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: NA 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 working 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments °wM 19 Mizzentop Lane Property Address Allen Mulligan Owner Owner's Name information is required for every Centerville Ma 02632 6-7-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 11 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-box is in working order at time of inspection with liquid level equal to outlet invert. D-box did not show signs of back up. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): NA * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 19 Mizzentop Lane Property Address Allen Mulligan Owner Owner's Name information is required for every Centerville Ma 02632 6-7-18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: (2) 500 gallons ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching was in working order at time of inspection with no sign of hydraulic failure. Leaching was 1/3 full when viewed with no higher staining. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration NA 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 l5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments °M 19 MizzentoP Lane Property Address Allen Mulligan Owner Owner's Name information is required for every Centerville Ma 02632 6-7-18 page. City/Town State Zip Code Date of Inspection 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 construction: NA Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 19 Mizzentop Lane Property Address Allen Mulligan Owner Owner's Name information is required for every Centerville Ma 02632 6-7-18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately Back Driveway RH] DECK A1-22' B1-26'411 1 A2.32' B2.22' A3.37`2" B3.23' 201,_ I t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts L Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ° M 19 Mizzentop Lane Property Address Allen Mulligan Owner Owner's Name information is required for every Centerville Ma 02632 6-7-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: No GW @ 132" feet 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: 1-8-02 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ 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: Plan on file with BOH. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 19 Mizzentop Lane Property Address Allen Mulligan Owner Owner's Name information is required for every Centerville Ma 02632 6-7-18 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:-Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE / . LOCATION �i 0111 Zx<---&rt ";2 0 SEWAGE # y,3 VILLAGE C=—1 ASSESSOR'S MAP & LOTA I � 0 INSTALLER'S NAME&PHONE NO. 46} ;7 SEPTIC TANK CAPACITY 14� LEACHING FACULITY: (type) 6, (size) NO. OF BEDROOMS f/ BUILDER OR OWNER S i!� /��'w PERMITDATE: `�' - COMPLIANCE DATE:;I- Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leach/ Facility Feet f Private Water Supply Well and Leaching Facility (If any w,e`lls exist on site or within 200 feet of leaching facility) �// Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) / Feet Furnished by i Z ? �' L Z t TOWN OF BARNSTABLE LOCATION (7s SEWAGE # VILLAGE 1'IOS Q✓ASSESSOR'S MAP & L0 �7 INSTALLER'S NAME&PHONE. O. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and.Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by peck AA Q �-D cl6 No. Fee5 0 ,Ve 3 qb THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 2pplication for Misspozal *patent Construction Permit Application for a Permit to Construct( . )Repair(x)Upgrade( )Abandon( ) O Complete System O Individual Components Location Address or Lot No. 19 Mi z z entop Ln Owner's Name,Address and Tel.No. Assessor's Map/Parcel Centerville Jeff Sutphen Lot 36 .r Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 3 9 8—8 31 1 W.E. Robinson Septic CrAIG Short P.O. Box . 1089 235 Gr Western Rd Type of Building: Harwich Dwelling No.of Bedrooms 2 Lot Size sq.ft. Garbage Grinder( p)p Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil ;a n rl Nature r ns rwhenapplicable) Install a new Title 5 Septic Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Bo d of health. -7 Signed ,�' / a Date Application Approved by 09 Date Application Disapproved for the following reasons 0 Permit No. Date Issued No. Fee �i() a O fl Entered in computer: % . THE COMMONWEALTH bF.MASSACHUSETTS - . Y PUBLIC HEALTH DIVISION -TOWN OF BARNSTAbIlEs MASSACHUSETTS F Zipplication for Mi000al *pzteni Co"truction Permit Application for a Permit to Construct( )Repair( x)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 19 M i z z ent op L_n Owner's Name,Address and Tel.No. ' Assessor'sMap/Paz Jeff Sutphen Centerville p . Lot 36 - Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 3 9 8—8 31 1 W.E. Robinson �Setic CrAIG lahort P.O. Box 1089 235 Gr Western Rd Centerville 77-Type of Building: -M77o - cn Dwelling No.of Bedrooms 2 Lot Size sq.ft. Garbage Grinder( r)o Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures -Design Flow gallons per day. Calculated daily flow gallons. `Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil sand • t - Nature e i r r ti sw w a applicable) Install a new Title 5 Septic -e� M&A& �.Q µ ;Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Bo of ealth. Signed / c Date A� } Application Approved by �" V Date Application Disapproved for the following reasons r 4 Permit No. Date Issued.--- THE COMMONWEALTH OF MASSACHUSETTS Sutphen BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired(x )Upgraded( ) Abandoned( )by W.E. Robinson Septic at 19 Mizzenton Ln CentPrvi 1 1 e has been constructe in accfordance with the provisions of Title 5 and the for Disposal System Construction Permit No. Zoo 3—0`{6 dated 2'1/bg Installer Designer The issuance oft s p rmit shall not be construed as a guarantee that the system/ i l as-de'signed. Date 2 Q Inspector No.-f��Y0�� ------------- Fee 50.0A_ THE COMMONWEALTH OF MASSACHUSETTS Or utphen ( PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Miq o6ar * 5tem Con!6trurtio Permit � p Permission is hereby granted to Construct( )Repair( x)Upgrade( )Abandon( ) System located at 19 Mizzentop Ln Centervillew and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be 1completed within three years of the date of this erm t. Date: Approved by .,. /`-- TOWN OF BARNSTABLE LOCATION 0111 !p SEWAGE # _0 3 ' VILLAGE �t''r� ASSESSOR'S MAP & LOT/ INSTALLER'S NAl E&PHONE NO. V SEPTIC TANK CAPACITY J � LEACHING FACILITY: (type)P.•-J � k 6, (size) /3 4- NO. OF BEDROOMS BUILDER OR OWNER 5 6 7-42 kn, PERMITDATE: ,�"' COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leachry�, Facility Feet Private Water Supply Well and Leaching Facility (If any w,e'ils,exist on site or within 200 feet of leaching facility) ,r' Feet Edge of Wetland and Leaching Facility(If any wetland/exist exist within 300 feet of leaching facility). Feet Furnished by i , Iw 8 G i i 6� a is z��•i COMMONWEALTH OF MASSACHUSETTS : EXECUTIVE,OFFICE OF ENVIRONMENTAL AFFAIRS ` ' DEPARTMENT OF ENVIRONMENTAL PROTECTION g << r v TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION •4i Y. Property Address: 19 MIZZON TO P WEST HYANNISPORT,MA 02672 aa� vlo�l "� ,i0 Owner's Name: GUIDOTTI .` Owner's Address: 267 HANLON LANE HOLLISTON MA.01746 ` yF Date of Inspection:3/2/01 N r ` Name of Inspector: (please print) JOHN GRACI ' 41 Company Name: SEPTIC4NSPECTIONS t, k Mailing Address: P.O.BOX 2119 TEATICKET,MA.02536 Telephone Number: 508-564-6813 FAX 508-564-7270 CERTIFICATION STATEMENT "y 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 sn s inspector pursuant to Section 15.34.0,,of Title 5(310 CMR 15.000). The system: " a ;s;is X Passes _ Conditionally Passes d _ Needs Furthe 'Evaluation by the Local Approving Authority Fails Date: 3/2/01 Inspector's Signature: The system inspector shall submit Lpy of this inspection report to the Approving Authority(Board of Health or DEP)withm 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,they ij inspector and the system owner shall submit the report appropriate ort to the a ro riate 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. �` pp Notes and Comments '` Rl�t THE SYSTEM PASSES TITLE V INPECTION. RECOMMEND PUMPING SYSTEM EVERY ONE TO TWO YEARS TO PROLONG THE SYSTEKS.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.4he system will perform in the future under the same or different conditions of use. 1 Page 2 df 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 19 MIZZON TO PWEST HYANNISPORT,MA 02672 Owner: GUIDOTTI Date of Inspection: 3/2/01 i:.,.4. Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D }�. A. System Passes: " n 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. �ft;54 Comments: , THE SYSTEM PASSES TITLE V INPECTION.RECOMMEND PUMPING SYSTEM EVERY ONE TO TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. t B. System Conditionally Passes: 4, _ 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 orrepair,as approved by the Board of Health,will pass. , KT 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 4 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 =` r pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of ;,tip-# Health): _ broken,pipe(s)are replaced #'9 _ obstruction is removed _ distribution box is leveled or replaced � L f ND explain: n/a ' � f s,, 9 r n/a The system required pumping more than 4 times a year due to broken or obst acted pipe(s). The system will pass inspection if(with approval of the Board of Health): _broken pipes)are replaced _obstruction is removed ND explain: n/a 1 S Page 3 of I I ' ' k OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORMr? PART A t` .CERTIFICATION(continued) Property Address: 19 MIZZON TO P WEST HYANNISPORT,MA 02672 £- Owner: GUIDOTTI Date of Inspection: 3/2/01 C. a'fiJ 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 x. protect public health,safety or the environment. ; y i aaf, 1. System will pass unless B�o'ard: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 i5. Z 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 ,f 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`tand SAS and the SAS is within 50 feet of a private water supply well. i _ 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 aP . ;q i.5 ,Page 4 of 11 n -a w` I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 19 MIZZON TO P WEST HYANNISPORT,MA 02672 Owner: GUIDOTTI Date of Inspection: 3/2/01 D. System Failure Criteria applicable to all systems: ; You must indicate"yes"or"no"to each of the following for all-inspections: ,4''<<t, ;,rly#, Yes No c 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 k P _ 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 day flow X Required pumping more than 4 times in the last year Nt7T due to clogged or obstructed pipe(s).Number of times pumped n&. X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool o'r°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 1 of a public well. _ X Any portion of a cesspool 6(: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 qualiy 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 ,�k from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or ,'n1 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 fails. 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'4o large systems in addition to the criteria above) ka;1 !r7 f 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])shall upgrade the system in accordance with 310 CMR 15.304.The system owner „ should contact the appropriate regional office of the Department. spa d�, ' /I Y 4 ,Page 5 of 11 + OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST i Property Address: 19 MIZZON TO P WEST HYANNISPORT,MA 02672 Owner: GUIDOTTI Date of Inspection: 3/2/01k. Check if the following have been done.You must indicate"yes" or"no"as to each of the following: 4 r Yes No X _ Pumping information wasti rovided b the owner,occupant,or Board of Health P g P Y P 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 wicovered,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? f n a 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 i information. For exam lea plan at the Board of Health. Existing o - X g P 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)] «y; 1 • pjpy 'a + r S i Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM -$ PART C SYSTEM INFORMATION Property Address: 19 MIZZON TO P WEST HYANNISPORT,MA 02672 Owner: GUIDOTTI Date of Inspection: 3/2/01 '' FLOW CONDITIONS 4 RESIDENTIAL T. Number of bedrooms(design): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.263 (for example: 110 gpd x#of bedrooms):220 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): YES Water meter readings, if available(last 2 years usage(gpd)): n/a Sump pump(yes or no): NO Last date of occupancy: n/a ;s: COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd x.? ,j Basis of design flow(seats/persons/sgft,etc.):�n/a `' a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO '2 t. + Non-sanitary waste discharged t6the 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 i 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 f TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system ` 't-, _Single cesspool Overflow cesspool is r.r t — _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 rnaintenance 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: v 1975 Were sewage odors detected when arriving at the site(yes or no): NO i, y r, •Page 7 of 11 .Z ti F OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ` SYSTEM INFORMATION(continued) ?' Property Address: 19 MIZZON TO P WEST HYANNISPORT,MA 02672 , + F Owner: GUIDOTTI Date of Inspection: 3/2/01 BUILDING SEWER(locate on site plan) Depth below grade: 12" Materials of construction:_cast iron =40 PVC Xother(explain): ORANGEBURG t, Distance from private water supply*ell,or suction line: n/a «.n Comments(on condition of joints,venting,evidence of leakage,etc.): TOWN WATER `t � SEPTIC TANK: X(locate on site plan) a°, k Depth below grade:2" ' Material of construction:Xconcrete'_metal_fiberglass_polyethylene other(explain)n/a i 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:6' X 6' BLOCK CESSPOOL" r Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle:32" Scum thickness: I" Distance from top of scum to top of outlet',tee or baffle: 6" I Distance from bottom of scum to bottom of outlet tee or baffle: n/a r? �! y 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.): ' MAIN CESSPOOL AND ALL COMPONENTS ARE STRUCTURALLY SOUND. RECOMMEND PUMPING EVERY ONE TO TWO YEARS TO PROLONG THE SYSTEM'S USEFUL a GREASE TRAP:_(locate on site,plan) Esc Depth below grade: n/a Material of construction: concrete metal fiberglass polyethylene other(explain): n/a — Dimensions: n/a T Scum thickness: n/a y 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,.): �!t t n/a . . i t' 1 y. e1Li FI 1 $ � Page 8 of 11 t OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 19 MIZZON TO P WEST HYANNISPORT,MA 02672 Owner: GUIDOTTI Date of Inspection: 3/2/01 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 r , Dimensions: n/a Capacity: n/a gallons i'a 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 ,r g Comments(condition of alarm and float swftaches,etc.): 'r n/a r • <9 DISTRIBUTION BOX:_(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: n/a 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.): a n/a n: 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 e 5,4• Page 9 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 19 MIZZON TO P WEST HYANNISPORT,MA 02672 i.. Owner: GUIDOTTI '� Date of Inspection: 3/2/01 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: r n/a • s Type n/a leaching pits, number: n/a 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 6' X 6' BLOCK CESSPOOL overflow cesspool, number: n/a E'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.): ;w THE OVERFLOW CESSPOOL IS STRUCTURALLY SOUND AND APPEARS TO BE FUNCTIONING PROPERLY.THE OVERFLOW HAD 2'OF LEACHING LEFT AT THE TIME OF .,..;INSPECTION. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) ; i 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) 4 , 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 py ,i n Page lb of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS x SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 1q, 4 Property Address: 19 MIZZON TOR WEST HYANNISPORT,MA 02672 Owner: GUIDOTTI 4 Date of Inspection: 3/2/01 f SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal*stem 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. f D ec� #` AA 3� �f3 4` $A �1 i. in „Page I'l of 11 f ' u PR 1 ri 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 19 MIZZON TO P,WEST HYANNISPORT,MA 02672 Owner: GUIDOTTI Date of Inspection: 3/2/01 SITE EXAM ° _Slope Surface water _Check cellar ,, Shallow wells t �i Estimated depth to ground water 10+feet :. A t Please indicate(check)all methods used to determine the high ground water elevation: '+ J , 1 NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a Y �P PAP , ;,.,.,,•. 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) f: YES Accessed USGS database-e;Cplain: n/a { You must describe how you established-the high ground water elevation: USGS MAPS AND CHARTS- 10+FEET 1 •,fir”, 6t ,r If.p SOIL TEST <TOP OF FOUNDATION 20 FT.'`MINIMUM FROM CELLAR 'DATE OF SOIL TEST ELEV. , 100.00 10 FT. MINIMUM 10 FT. MINIMUM_FROM SLAB OR CRAWL SPACE SOIL TEST DONE BY imps ; CLEAN SAND WITNESSED BY y./� r w &0% .557, (ASSUMED) CONCRETE COVERS LOAM AND SEED OBSERVATION HOLE 1 ELEv.= . 40 SCHEDULE 40 PVC PIPE PERCOLATION RATE. MIN:/INCH 'AT 4:2a.fi"•�INCHES MIN. PITCH 1/8" PER FT. 2` -LAYER OF DEPTH HORIZ TEXTURE COLOR MOTT.- OTHER 1/8" TO 1/2" . � .Caatir^y loyil! " L`C'q'� A WASHED STONE h• VENT 4, 19P $a n cJl. 3P, 4« CAST IRON PIPE (OR EQUAL) MINIMUM NOT REQUIRED PITCH 1/4" PER FT. FLOW LINE PLUMBING ELEV. 97. 10` O 0 o 0 0 0 ❑O [� 1 TO BE RAISED MIN. .0» o o ° N11. u.•►t 3 . ELEV• 2 ❑0000000000 AND.RE-PIPED BY p4 d 60 SUMP LEVEL !30 ° o ° LICENSED PLUMBER ELEV. _ ,!_____ GAS ELEV. = q 2• ELEV. a /• o 0 BAFFLE DISTRIBUTION ° o O O O D O D C]tO O 0 C] a 2' o sa act AS NEEDED ELEV. _ ° o° 0 E3 0 E7 0 D D 0 0 0 ❑ U ID OUTLET BOX 9o.2S o o a ° ° ° ELEV. .: _ Z 5 ET 14 INCHES (TO BE PLACED ON FIRM BASE) TO BE WATER TESTED. 2 r 500 GALLON DRYWELLS WITH STONE IN AN 6 FEET 24 INCHES 1500 GALLON IF MORE THAN ONE OUTLET ! ,5-,2� P JO WATER ENCOUNTERED AT ELEV. ZZ Tf V 8 FLEET 34 INCHES SEPTIC TANK (TO BE PLACED»ON FIRM BASE) 13 J�?sue C- TRENCH-FORMATION WELL rv�r4 3/4 TO 1 1/2 CLEAN SOIL ABSORPTION ` INDEX DOUBLE WASHED STONE ADJUST DESIGN CALCULATIONS FREE OF FINES +6c SILT SYSTEM (SAS) USGS PROBABLE WATER TABLE ELEV. _ ^���+ NUMBER OF BEDROOMS SEWAGE DISPOSAL SYSTEM PROFILE OBSERVED WATER TABLE ( / / } ELEV. _ T GARBAGE DISPOSAL UNIT _ NOT TO SCALE TOTAL ESTIMATED FLOW BOTTOM OF TEST-HOLE ELEV. //� X 3 �YN 3c� GAL./bAY. REQUIRED SEP11C TANK CAPACITY GAL ACTUAL SIZE OF SEPTIC TANK � GAL. . SOIL CLASSIFICATION DESIGN PERCOLATION RATE MIN./IN. EFFLUENT LOADING RATE ! •7 GAL./DAY/S.F. LEACHING AREA I V.X 2 �F- 74.e 1 4-7 7 SO. FT. LEACHING CAPACITY (AREA X RATE) -- GAL./DAY 477 A, RESERVE LEACHING CAPACITY i GAL./DAY NOTES: 1. ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO D.E.P. TITLE 5 AND THE TOWN RULES AND REGULATIONS FOR THE SUBSURFACE DISPOSAL OF SEWAGE. 2. ALL COVERS TO SANITARY UNITS SHALL BE BROUGHT TO WITHIN 6' OF FINISHED GRADE. 3. ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE CAPABLE OF WITHSTANDING H-10 LOADING UNLESS THEY ARE UNDER OR WITHIN 10 FT. OF DRIVES OR PARKING AREAS, H-20 LOADING SHALL BE USEDUNDER OR WITHIN 10 FT. OF DRIVES OR PARKING AREAS. -4. ANY MASUNRY UNITS USED TO BRING COVERS TO GRADE SHALL \ BE MORTARED IN PLACE.:_ 5. NO DETERMINATION HAS BEEN MADE AS TO .^.CC}}MMP 1 -MCE WITH ' DEEDED OR ZONING REGULATIONS. OWNER J APPU ANT IS TO OBTAIN SUCH DETERMINATION FROM APPROPRtA AUTHORITY. 6. UTILITIES SHOWN ARE APPROXIMATE ONLY. EXCAVATION CONTRACTOR IS TO CALL "DIG-SAFE"-AT 1-888 '344-7233 ■ 88.8 AT LEAST 72 HOURS PRIOR TO COMMENCING WORK ON .SITE. 7. CONTRACTOR IS TO VERIFY GRADES AND ELEVATIONS AS WELL AS SITE CONDITIONS PRIOR TO COMMENCING WORK,ON SITE. f ANY VARIATION .IS TO BE BROUGHT TO THE ATTENTION OF THE DESIGN ENGINEER IMMEDIATELY. 8. PARCEL IS IN FLOOD ZONE C 9. LOT 1S SHOWN ON ASSESSORS MAP -$7 AS PARCEL 10. ALL UNSUITABLE MATERIAL SHALL BE REMOVED FROM UNDER, AND f-(96J� FOR A MINIMUM OF 5 FEET FROM AROUND T14E SOIL ABSORPTION ` F, SYSTEM, AND BE REPLACED WITH SAND AS SPECIFIED IN 310 1" l P7 �� 97.2 �� i .- r r•, . CMR 15.255: (3)(LE. TIRE 5) IF ENCOUNTERED BELOW S.A.S. A wt Ac' �N OF ... \- * "EQ1 R1 PIPE INVERT. N / / �r (98)-� �Z..9 �, ' _ ,� s *�, 11. EXISTING "SEPTIC SYSTEM TO BE PUMPED AND FILLED WITH SAND .�? OIiIC, ( .� Q CO e� SFJOE33 s ` k"U `�� OR REMOVED. 99.5 r 98.8 !� CIVIL . .. 4 �- APPROYGD: B0/'1RDf� HGJ'1L NO.274883 a '� 98.3 100.3 4.4 / � `�<<,► � t ��( DATE `AGENT: ��K 100.8 s,- 7 w �, PROPOSED SEPTIC DESIGN _ ''' 1ti FOR GO I L i 14 7.8 2 100x 100.6 9.8 v tl G V s J `7 }= C AR£A 7,500t SF.f 9 4t r F V T ' .99.7C 9 9.4 ` O MI z'zEwroP G� LOC s� IAN� o LOT. 36, 19 =ZENTOP IN • 101.� k��, s`'� BARNSTABLE (CIMTEX)TAs �1 � 99.7 CRAIG P. $Wffs PAt 00.9 `�" Q 235 GREAT WESTERN ROAD 99.7 .� 508- P. 0. BOX 1044 398-8311 SOUTH DENNIS, .MASS. 02660 ti • 99.7 ti DATE JAN 8, 2002 SCALE >, 0' N rz.ta. . CJt `r/Jt • REVISED .IOB ,NO• 01-�0950 LOCATION MAP REVISED SHEET 1 OF C. S8 PROD 2406-00 dw 2406-OO.DMC 0 21302 CRAIG:-R., SHORT,' P.E.