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HomeMy WebLinkAbout0099 OLD FARM ROAD - Health 99 Old Farm Rd Centerville A=231 - 026 S M E A C No.M163OR UPC 10259 smead.com • Made to USA �o). Commonwealth of Massachusetts Title 5 Official Inspection Form copy Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 99 Old Farm Road Property Address Roy Cowing Owner Owner's Name information is required for every Centerville MA 02632 October 14, 2014 page. City/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. Important:When A. General Information filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not Patrick T. Sullivan use the return Name of Inspector key. Ready Rooter Excavating r� Company Name P.O. Box 89 Company Address Forestdale MAOr1644 City/Town State &M Code _, ,4P � 508-888-6055 S112843 ;�') Telephone Number License Number h� F� 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 %:' ---� October 15, 2014 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. 1 *111 t5ins•3/13 Title 5 Official Inspection Form: s rf ce Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 99 Old Farm Road _ Property Address Roy Cowing Owner Owner's Name information is Centerville MA 02632 October 14 2014 required for every , 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: Edge of pond is >120'from edge of SAS. 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 yea old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltrationa or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is repl9ded with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass i spection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that th tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 99 Old Farm Road _ Property Address Roy Cowing Owner Owner's Name information is required for every Centerville MA 02632 October 14, 2014 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 levele 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 Bo�d of Health): ❑ broken pipe(s) are replaced ❑'Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Requir by the Board of Health: further evaluation by the Board of Health in order to determine if El Conditions exist which requi 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 99 Old Farm Road Property Address Roy Cowing Owner Owner's Name information is required for every Centerville MA 02632 October 14, 2014 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 a 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 nalysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent an the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided tha o 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 %day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 99 Old Farm Road Property Address Roy Cowing Owner Owner's Name information is Centerville MA 02632 October 14 2014 required for every , page. Cityrrown 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 ithin 400 feet of a surface drinking water supply ❑ ❑ the syste is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the sy em is located in a nitrogen sensitive area (Interim Wellhead Protection Are —IWPA) or a mapped Zone II of a public water supply well If you have answered " es' to any question in Section E the system is considered a significant threat, or answered "yes" in ection D above the large system has failed. The owner or operator of any large system considered 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,. 99 Old Farm Road Property Address Roy Cowing Owner Owner's Name information is required for every Centerville MA 02632 October 14, 2014 page. Cityrrown 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 CM 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 502 GPD l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments N 99 Old Farm Road _ Property Address Roy Cowing Owner Owner's Name information is required for every Centerville MA 02632 October 14 2014 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Property has one bedroom in main house and one bedroom in "cottage". Number of current residents: 2 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 years usage (gpd)): GPD 2012012= 2241 41 GPD Detail: Higher water usage in summer months due to irrigation. Average Jan-June 2014= 138 GPD Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on/R5 : Gallons per day(gpd) Basis of design flow(s ., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holdin ❑ Yes ❑ No Non-sanitary waste dile 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 99 Old Farm Road Property Address Roy Cowing Owner Owner's Name information is required for every Centerville MA 02632 October 14, 2014 page. City/Town 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: Ready Rooter records: Pumped 05/09/14 + 04/05/13 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 99 Old Farm Road Property Address Roy Cowing Owner Owner's Name information is required for every Centerville MA 02632 October 14, 2014 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: System installed 07/13/1986. Certificate of Compliance on file at Health Dept. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan).- Depth below grade: 4 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: n/a feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: 3 over inlet, 4 over outlet 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: 10'6"X 66"X 5' 1500 gallons Sludge depth: 1° t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 99 Old Farm Road Property Address Roy Cowing Owner Owners Name information is required for every Centerville MA 02632 October 14, 2014 page. Cityrrown 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 1 Distance from top of scum to top of outlet tee or baffle $ Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? Tape measure and dip tube. Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet PVC tees (2) and outlet concrete baffle in place.Liquid level at outlet invert. Risers bring covers within 6" of grade. 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 op of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle I Date of last pumping: Date l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 99 Old Farm Road Property Address Roy Cowing Owner Owners Name information is required for every Centerville MA 02632 October 14, 2014 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: Material of construction: ❑ concrete ❑ metal ❑ fiber,71r, ❑ 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 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,. 99 Old Farm Road Property Address Roy Cowing Owner Owner's Name information is required for every Centerville MA 02632 October 14 2014 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" 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.): One inlet, one outlet. 4' below grade. Riser brings access cover 6" below grade in stone walkway. No sign of leakage. No high water staining over outlet invert. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No' Alarms in working order: ❑ Yes ❑ No" Comments (note condition of pump cha /r, condition of pumps and appurtenances, etc.): * 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 Farm:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 99 Old Farm Road Property Address Roy Cowing Owner Owner's Name information is required for every Centerville MA 02632 October 14, 2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1-6' X 4'w/4' of stone. ❑ leaching chambers number: ❑ 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.): Liquid level 1'4" below invert at time of inspection. Two rows of holes with clean stone visible through side wall. No sign of past hydraulic failure. Leach pit located and inspected with camera. 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 t5ins•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 99 Old Farm Road Property Address Roy Cowing Owner Owner's Name information is required for every Centerville MA 02632 October 14 2014 page. Cityfrown 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: Dimensions Depth of solids Comments (note condition of soi, signs hydraulic failure, level of ponding, condition of vegetation, etc.): l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 99 Old Farm Road Property Address Roy Cowing Owner Owner's Name information is required for every Centerville MA 02632 October 14, 2014 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 A t. 1- 00 j 2) ©r b i� ar- t5ins•3113 Title 5 official Inspection Fonrc Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 99 Old Farm Road Property Address Roy Cowing Owner Owner's Name information is required for every Centerville MA 02632 October 14, 2014 page. Cityrrown 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: >5 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: Nov. 13, 1985 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with focal Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database -explain: maps.massgis.state.ma.us/oliver.php You must describe how you established the high ground water elevation: Test hole in 1985 found no ground water at 12'. (elv= 37.50) Base of leach pit at elv=41.5. Slope to pond drops well below base of leach pit. 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 f Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 99 Old Farm Road Property Address Roy Cowing Owner Owner's Name information is required for every Centerville MA 02632 October 14, 2014 page. Cityrrown 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 15ins•3113 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System-Page 17 of 17 f Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 99 Old Farm Road Property Address Roy Cowing Owner Owner's Name information is required for every Centerville MA 02632 October 14, 2014 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 l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 I i I Ir • —y�car 9�maucr• i - - I. MIT ly OF z:Ya vcaA'f�; o j (a06YVI i 2x4 FPr yrLs: C'I __ I�'eloc�osuwiaml � iv.y . ---p11xK �u tt1 amr i r 3'-- - �rncE.. •.I�o. �YKo PeOPOU D. AccC5,0 �fDRoom a S r(u�ru RE w;NG NUMdE� .. LAKE �,; UAQ T UE b ,/ ,�� WEQ i LOT 5 13� 63 =____-_______= W LOT 6 2 DECK �✓ a w--=3'-- 1 LOT 4 W 1 O K- i NOTE.- 10 0. goAD PRE-EXISTING 3,12' NONCONFORMING s5 F AJ- " 0(1 o - RES. ZONE. "RD-1" This MORTGAGE INSPECTION Plan is For FLOOD ZONE. ,C" Bank Use Only TOWN: -CE-N-TMUL4E________- REGISTRY OWNER: ROY T. -CGWING JR____________ DEED REF: -_aZ51d4-8--------BUYER: JMFI1 ffCE------------------------- DATE: _8 ��93 ------------ PLAN REF: _16�69_____ _____SCALE:1"= 30=__FT. I HEREBY CERTIFY TO CAPE'COD FIVE ____________ _C_E_NT_S _SAVINGS BANK_ ___THAT THE BUILDING YANKEE SURVEY SHOWN ON THIS PLAN IS LOCATED ON THE GROUND AS SHOWN AND THAT ITS POSITION DOES ---_ CONFORM w+' , CONSULTANTS TO THE ZONING LAW SETBACK REQUIREMENTS OF THE 1 40B (SUITE 5) TOWN OF _ BARNSTAU E_____________AND THAT - ' - INDUSTRY ROAD IT DOES_ NOT_ LIE WITHIN THE SPECIAL FLOOD HAZARD + MARSTONS MILLS, MA. 02648 AREA AS SHOWN ON THE H.U.D. MAP DATED_ 19�85 _ ,t�'L .. `" F'' TEL: 428-0055 Co unit —Panel # 250001 0005 C FAX 420-5553 _ _____ THIS PLAN NOT MADE FROM—AN INSTRUMENT 12073 KJH PAUL A. MER TH PIS SURVEY NOT TO BE USED FOR FENCES ETC. p�Y :Y Q star&IN W k:l 5. 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THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH,-- -_ sqB .................................. s ,��r rlirtt ilatt�for wpnstt1 Works Toni rur tnn a uti Application is hereby made for a Permit to Construct ( ) or Repair (,,fan Individual Sewage Disposal System at aG7j �-,927 2o�r� E�/T �r�L !.� Location-Address or Lot No. --� ° -.....�- ----•----------------------------------------- ....... ..... ... ..........._....-- Owner Address W =i4 4._13.............•----------.._.. -.----------------------------------------.--- ..........._.......-.---------.---------------------------------------•--------------.----------- a Installer Address Type of Building Size Lot.....8........v...._.Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers ( ) — Cafeteria ( ) Q+ Other fixtures ._------.---•---•--------------------------------- ---------------------------------------••-------•----------------------•--•---•----------•------- d gallons per person per day. Total dail flow.................33�_......._...._.gallons. Design Flow `sue .� WSeptic Tank—Liquid capacity./��.gallons Length... Width................ Diameter................ Depth..t.�.y.._- x Disposal Trench—No--------------------- Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No------1........... Diameter................._.. Depth below inlet---:�....... Total leaching area.-3o?-:.8-.sq. ft. Other Distribution box ( ) Dosing tank ( ) Z 13 Percolation Test Results Performed b ..........................................� � G l•-----•••••• Date-Na .... � y , / 7-----------•------ ,,a Test Pit No. I...L.Zn__..minutes per inch Depth of Test Pit-__._� ..... Depth to ground water...... ............. Test Pit No. 2................minutes per inch Depth of Test Pit..................... Depth to ground water........................ pG -••----•-----•-----------------------•-- ------• ...... 0 Description of Soil 6�� 3v•�� � ......................................................�i3_SoiL =7Z,. CoA:rr...sC..... �...1....---.... U 1 z ........ 7z_.._ /��` Gib/ '�sG. 5 -'`ice• ------------- •-----------•-••--•------••----•--••----....-•-•--..•............---...... - ------------- Nature of Repairs or Alterations—Answer when applicable : _._ `a --- U P PP ---------- .... --------•---=------•-------•------------------•-------....-----...-----------............--•------------.....---•-----•------•--------•----------------•------------•----....------•----------------•--- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System.in accordance with the provisions of TITLE 5 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 health. Signed .......................................... -- - - ate Application Approved BY :... ... -----•-•--••.-••------------------------•--..... ------------.. Date Application Disapproved for the following reasons:-----•--------•----------------------------•---------........................................................ --•---•----------------------------------------------------------••-•----•-------.......-•--------------------•---......-------------------•------•------•--•----------••-•----------------•------••---- Date PermitNo............ - ..... ----- --------------------- Issued........................................................ %P.Co ^,t1 7 Date No.. Nil/ Fic3i THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .............. ...........OF.........��.. ................................... Appliratiun for Disposal Works Tonstrurtion ;.ermit Application is hereby made for a Permit to Construct ( ) or Repair (--'10'an Individual Sewage Disposal System at:..06T?- '="---f2°=`Yra- G Tc� r/iLGG....._...-- ............ . ...........47 _- s .._.........•----...............---...... Location-Address or Lot No. W ....A Owner Address ................ ........ ........«........ a .............. • ------............. .......... . ...... ......._.......... Installer Address UType of Building 3 Size Lot.... p.U......Sq. feet Dwelling—No. of Bedrooms.......................:....................Expansion Attic ( ) Garbage Grinder ( ) a`-4 Other—T e of Building ....... No. of persons............................ Showers YP g --------•------------ P ( ) — Cafeteria ( ) dOther fixtures ------------------ -------•.--------•-------.----- ._---------•-----------•-------•--..........---•-----------......-•••••----....•--...--•-------- Design Flow................... .................gallons per person per day. Total daily flow................... gallons. ,3 3 0 WSeptic Tank—Liquid capacity.�r"Rgallons Length.... .��.",- Width.._............. Diameter................ Depths.:.`?1.. x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No......./........... Diameter...... ............ Depth below inlet.._3. ...... Total leaching area...3c :$.sq. ft. Z Other Distribution box ( ) Dosing tank ( ) _ Percolation Test Results Performed by...... .x??4,"'"'2 � 0!........... Date..NO I/ -T/,,9 y4 • ....... Test Pit No. 1...G__Z....minutes per inch Depth of Test Pit......e :---- Depth to ground water...............,... f=I Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a .................................. -............---...... 0 Description of Soil-----.-6��' -----•-----•-• ��' 4'�'"� S�. �_ S©� yo -'Z" r sC- S c> •---•------------- --•--•-------------------------•------....------...........----.......................•-----... ........... ,. . --------------------••---•--------•---------........---..._....------------------------------------.........:-................---------•-------...•..... U Nature of Repairs or Alterations—Answer when applicable..___. ...Q�Q ::_ .........4 0�-�V,Q.... .. ----------------------------•...................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System.in accordance with the provisions of T ITL1- 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..... ........... -------------------------------------------------------- -------------------------- �l� p�/_ Application Approved By---------- ---j- = = �=�=-`�`�• -•--------•--•------•--.........._ ---------; ....1:..._. Date Application Disapproved for the f ollozIt ing reasons:.......................................................-................................................----- .................•-••-....--••---•-•-......-----......--••--.......•---••-----..........--••-------.......-----------•--.....----••---------••--•--.......-----•--•--•----..........-•-------.......... Date PermitNo...........•=-�---.-------1-4..............«.._ Issued........................................................ G?r^ _ Mj� Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...................mod .`. OF.........�.�z! ......................................... ............. ..... .................. T of irate of Tumplinurr THIS_IS TO CERTIFY, That the Individual Sewage Disposal System constructed (ter Repaired ( ) by............. --••�- ---t----�....... �.........................................................--•-•---..............................--•--•-•--..........._....... ......._ . Installer atL.'14 J ��_: �. I =,- C_.c;:1..............•----•-----••------.................-----------•-••---------•-- has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.._____L_ ..'�'7�f_....--. dated.....,/.� ------------------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE........... L4..'?6............................................... . Inspector........ ................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ��� ! �...........OF.....----� -r2wST�f�G ...'� .......................... N `_ Fzz........................ Disposal Works Tunstrixrtion Permit Permission is hereby granted............... TM J + { / ..................--•--:---. ....---------..----------..........._....................................««__ to Construct ( �) or Repair (co-�-an Individual Sewage Disposal System at No........L.r.'—..... y---.5...--.......� ��.c�._..f : :r ^^----.-..1_:13.._.... 2 n_)--... ............. Street as shown on the application for Disposal Works Construction Permit No: �.. 1�.. Dated... _!-,� �/ `:................... Board of Health DATE.............� ...?� FORM 1255 A. M. SULKIN. INC.. BOSTON �F r~ bV&qvAC)w&.r LsYKGf �33 Jc \ G E35�Ua G (ro 1 I �ztv 7-p OF 00. Y SOS •\\.. _ !o `_ \ .0 6 Sl' V6 2c. 3� 00 . SaPnc -46 Vb e�yC, 3pf � _ h A107Z-- AZPY-*770nis BASlrV d.V s/7— LOCATION SCALE DATE /�8G PLAN REFERENCE . ..6&7AIC . 4)7- �`'�.. . w.v a,v o EDWED, / . . . . . . . . . . . . N.LEY N . . . . . . . . . . . . . . . . . . . . 9 iVo. 26100 ,o I CERTIFY THAT THE �ECISTE4``�,�rk. SHOWN ON THIS PLAN IS LOCATED ON THE GROUND ss/�yAL LAN��v AS SHOWN HEREON AND THAT IT CONFORMS.TO THE SETBACK REQUIREMENTS OF THE TOWN OF . . . . WHEN CONSTRUCTED. DATE � . . . . . . . . .. . boy �oWi�G� .7R- PZ-? 7710AI,&-2 REGISTERED LAND SURVEYOR i I • TOP OF FOUNDATION s _ CONCRETE COVER CONCRETE COVERS t 4"CAST IRON II2"MAX. � 12"MAX. OR SCHEDULE 40 P.V.C. PIPE 4 SCHEDULE 40 PV.C.(ONLY) PITCH 1/4"PER. PIPE- MIN. LEACH PITCH 1/4"PER.FT. PIT PRECAST . ?'o e' INVERT o N-2o J LEACHING e•e as90 Q EL• SEPTIC TANK INVERT DUST INVERT ?� w q.� PIT OR e.e INVERT — ELS BOX EL4s/( • ; EQUIV. �✓`GO. .... GAL. INVERT 3,s ►- '�' e� EL 4SG� 5"33 INVERT va �' IN, 3/4"TOIVZ . l EL �.... 4SOo �'% 4W.W • EL. :. � �n• WAS W .;'� STONE •�, /4-' DIA ��.�rrLeo PROR LE OF GROUND WATER TABLE SEWAGE DISPOSAL SYSTEM NO SCALE P- si,3z SOIL LOG WITNESSED BY : DATE .M V. /3 TIME. 14:1SrA`7 .`T'��?4`s5 . a �Lo� . BOARD OF HEALTH TEST HOLE I TEST HOLE 2 G�ti/�o�p �: Z�E�! ENGINEER ELEV. . .I :s4. . . ELEV. .. .. . . . . . . DESIGN DATA : E-z.47.00 3 NUMBER OF BEDROOMS TOTAL ESTIMATED FLOW . . .'33�. . . GALLONS/DAY 7Z" _ �Z.43,So BOTTOM LEACHING AREA S 3 S, , SQ.FT. /PIT/C.P.D, SIDE LEACHING AREA . . . .�'S'3� . . . SQ.FT./ PIT1-348.8c,RD, CoA2S� SA�vo GARBAGE DISPOSAL . !�!?"��. ,(50% AREA INCREASE) TOTAL LEACHING AREA . SQ.FT PERCOLATION RATE � .7lV4-J.7lVo. MIN/INCH WATER ENCOUNTERED LEACHING AREA PER PERCOLATION RATE ?:7. SQ.FT�G;RD No• , NUMBER OF LEACHING PITS . . . . . . . . . . . . . . . APPROVED . .. . . . . . . . . . . BOARD OF HEALTH u� �E�' • �'C'S�N • �"`� fI2L .SAD,. . DATE . . . . . . . . . . . . . . . . . . . . . AGENT OR INSPECTOR OF pd,�ssc. LoT C.2 LL ' U t,�ELLEY N 27 GG D Fii� 20<►� ?, /"N o. 26100 �s 9FCISTER " /STba� .��?�??V/GG��•!'7�ISS, s��yAL LANaS sAN_RAP�A� PETITIONER ,?o-y J TOWN OF BARNSTABLE LOCATION ��, Q� , '--*r � �?r0 SEWAGE# VILLAGE C,—,V—V�e-=,^1.u,\� ASSESSOR'S MAP.&PARCEL DNA &PHONE _-- SEPTIC TANK CAPACITY 1 SO a .S),( "e.. � LEACHING FACILITY.(type) (size) NO.OF BEDROOMS tc t—) S—iow-Z OWNER�e1� C PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility S Feet Private Water Supply Well and Leaching Facility(If any wells exist ori' 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 ��n�- ��4�1'� ,,�r �� A r P � 3� 3r 0 1 ' 3 ' 6 l 1 3a� 3gs6� � �L1, 33 o1 k #: STA LLEP'S N AMi E i� A D 0 LESS v ®w I n � ;�_ -712 DA1 E C0MPLIANCf ISSUED �� �� /-Ir a ,� 1 \ 6 � � a � y 1. I 1