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Home My WebLink About0037 MARSTON AVENUE - Health 37 Marston.Avenue Hyannis P A = 288 130 �j y o TOWN OF BARNSTABLE LC AT1ON_3 ��rs SEWAGE # VILLAGE 4PIN)g�� ASSESSOR'S MAP & LOT INSTALLER'S NAME 6r PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) NO. OF BEDROOMS 3 PRIVATE WELL OR UBLIC WAT BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No i V /G l L .,� .�. Town of Barnstable Regulatory Services Richard V. Scali,Interim Director * iARNbTAB1E. NAM Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer&Designer Certification Form Date: I Z-2 Z.)L Sewage Permit# 20/6- y0 I Assessor's Map\Parcel g2 RL 130 Designer: ' y�� ''j, �,1� Installer: 3,43 EXCaV0Ai0A Address: � l0 � Address: y TcaScrrw L&2 F0rr-S-lda(C On EXCa ya�A i oA was issued a permifto install a (date) (installer) septic system at '37 M based on a design drawn by , (address) � 1C) dated I (designer) certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above-was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. Strip out(if required) was inspected and the soils were found satisfactory. I certify that the system referenced above was constructed in co nliance with the terms of the IAA approval letters (if applicable) t tlFr{q\: AVID (Installer's Signa ); MASON Fri � No.1066 0 ��G1STE�� w N1TAf�� e er s Signature) (Affix Desi :�,.;, mp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. QASeptic\Designer Certification Form Rev 8-14-13.doc f V No. l 0 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in co pute., Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS appliLation for Application for a Permit to Construct( ) Repair( IBtI Upgrade( ) Abandon( ) ❑Complete System ndividual Components Locati�on Address orLot No.3 J Qr�tUn AY f- owxn�r's Name,Address,and Tel.No. ` Assensbr�Map/Parcel ay Po rce j /3 n G S /f f S0�`�78,'S (�73 Installer's N e,Address,and Tel.No. Designer's N anae,.Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers Cafeteria YP g ( ) ( ) Other Fixtures Design Flow(min.required) 13130 gpd Design flow provided gpd Plan Date 11 Number of sheets Revision Date Title ^� Size of Septic Tank t {6f(n��,�(�'/ Type of S.A.S. Description of Soil Nature of RepEkirs or Alterations!,Ans when applicable) Date last inspected: 0 �' �'► P�/'�C w Iv e/�, Agreement: u// The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal systeJ2,I 7 r l 6 accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Bo d of th. Si ne 9" Date 1 ( � /o`l jp Application Approved by Date Application Disapproved by Date for the following reasons Permit No., 2,64 — Clot Date Issued T � 01 Fee v No � , THE COMMONWEALTH OPMASSACHUSETTS Entered in co pater: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS es ' application for �IBtI , aY *pstrm Construction permit Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) ❑Complete System ndividual Components Loc�es,r'sMlp/kcel n Address or Lot No. 3 01' Y Owner's Name,Address,and Tel.No. Ass z 84� po tC e 1 /3/ No n `�78•. 5 �� Installer's Name,Address;-and'Tel.No. Designer's Name,Address,and Tel.No. �t� �XCoVOJrUn 5A 977-vt�3 NVIOk(a5dn 6 Type of Building: Dwelling No.of Bedrooms y Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures '� ✓ Design Flow(min.required) gpd Design flow provided gpd Plan Date 7' �p Number of sheets Revision Date Title Size of Septic Tank tyusiinr4 Type of S.A.S. �- Description of Soil Nature of Repairs or Alterations(Ans when applicable) 1 ? N� bQY_ ( 2 ) 5 ctl �G�c� n� b,'r e 1 X� � 1 Date last inspected: Agreement: f The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage 09spPosal system in accordance with the provisions of Title 5 of the Environmental Code:and not to place the system in operation until a Certificate of Compliance has been issued by this Boa d of th. r ' Si a Date Application Approved by , Date I]— Application Disapproved by Date for the following reasons Permit No. 2 G b / U J Date Issued / 1-- /y—{ 6 ---------------------------------------------------------------------------------------------------------------------_----------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS (Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(L/) Upgraded( ) Abandoned( )by (U at 3:7 ,I f has been constructed in accordance with the-provisions of Title 5 and t e for Disposal System Construction Permit No. G ( _ 1/�/dated 11 1 y// Installer o b f r r w a)Y Designer Q v #bedrooms Approved design flow gpd The issuance of this,permt shall not be construed as"a guarantee that the system willfc)t ,,ird,'s,�i�edL.Date 2 1 Inspector -------------------------- ------ --------------- ---------- w---- ---------------- ------- -- .per, .tea..•x �+'.i ��+y�J �. . 1 ��. .. -.. j.. ______ No. au ( � — -/�� J 1 A �t' +Fee () U THE'COMMONWEALTH OF:�MASSACHUSETTS PUBLIC HEALTH DIVISION€y BARNSTABLE,MASSACHUSETTS 'disposal *pstem �Coristructioit, ertnit Permission is hereby granted:An truct( ) Repair( ) Upgrade( ) Abandon System located at `) ! r,) �(D n 6\(� I y n A j j Ol)r) and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction m st be completed within three years of the date of this permit. Date Approved byJ pfln11f1'i ° • u7 ti 0 CO , F I C ,I A CO Postage $ kel 18 D216.ark aCertified Feep Retum Receipt Fee CT 18 O (Endorsement Required)O Restricted Delivery Fee(Endorsement Required) O r3 O Total Postage&Fees rq Sent To f1.J c.J�'��f d�✓1�I r ------------- Streef Apt.No.; �d,B�X or PO Box No. U City State,ZIP+4------------------------ -— — ........ Y.. Certified Mail Provides: o A mailing receipt n A unique identifier for your mailpiece o A record of delivery kept by the Postal Service for two years Important Reminders: • Certified Mail may ONLY be combined with First-Class Mail®or Priority Mail®. o Certified Mail is not available for any class of international mail. o NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. o For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPS®postmark on your Certified Mail receipt is required. o For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery". a If a postmark op the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANISave this receipt and present it when making an inquiry. PS Form 3800,August 2006(Reverse)PSN 7530-02-000-9047 COMPLETE •N COMPLETE THIS SECTIONON DELIVERY E Gomplete items 1,2,and 3.Also complete AAMWature item 4 if Restricted Delivery is desired. ❑Agent ■ Print your name and address.on the reverse X 0 Addressee so that we can return the card to you. R cei ed by(Printe a C. Date of Delivery ■.Attach this card to the back of the mailpiece, or on the front if space permits. D. is delivery addrosdifferent from item 1? ❑Yes' 1. Article Addressed to: If YES,enter delivery address below: ❑No 11 660—�, SVW I a� Fo °/ - SPnf 3. S Ice Type / ertified Mail® ❑Priority Mail Express'" 0 Registered 3WReturn Receipt fnr Merchandise ❑Insured M2il ❑Collect on Delivery 4. Restricted Delivery?(Extra Fee) O Yes 70-1 1}010 000�0 �2847. 8�F25' ! �PS Form 3811,July 2013 Domestic Return Receipt I I UNITED STATESai,� ;; t First-Class Mail N Postage&Fees Paid . : USPS * ,, Permit No.G-10 1X .. • Sender: lease print your name, address, and ZIP+4®in this box* -7wvr 0 I 'FOI i�iiili�''i{ ij�ii,ijiii.,ijPiiipiiiii,i�'►'tftliltr'',i'iil�1�'ii' li THME Town "of Barnstable Bar�nStable . Regulatory Services Department MAme'caC j BAMSfABM 'NAB Public Health Division 9^ 1639. m 'bp�fDNA 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 7012 1010 0000 2847 8025 October 17, 2016 Scott.Smith PO Box 725 Hyannisport, MA 02647 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 37 Marston Avenue, Hyannis,MA was inspected on 09/28/2016 by Sean M. Jones, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Fails" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: • Leaching facility with standing liquid level at or above the invert pipe (per Town Cod3360-20 h). You are ordered to repair or replace the septic system within two (2)years from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF T E BOARD OF HEALTH Thomas McKean, R.S., CHO ` Agent of the Board of Health Q:\SEPTIC\Letters Septic Inspection Failures or Future Evl\37 Marston Avenue Hyannis.doc THE Town of Barnstable + HARN57'AHLE, 6� ,m� Regulatory Services Department Public Health Division 200 Main Street,Hyannis MA'02601 Office: 508-862-4644 Richard Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO Feb 6, 2007 Rev. 5/11/16 DEADLINES TO REPAIR FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15,000) An"x" marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑ Discharge or ponding of effluent to the surface of the ground ❑ Pumping more than 4 times during the last year not due to clogged or obstructed pipe. ❑ Backup of sewage into the house due to an overloaded or clogged SAS'or cesspool ONE (1)YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution.box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑ Any portion of the cesspool within a Zone 1 to a public well ❑ Any portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2)YEAR DEADLINE CRITERIA ❑ Single Cesspool ❑Any"conditionally passed systems" (broken cover,relocation of a pipe, relocation of a driveway due to H-10 components, etc) ❑ Leaching pit or cesspool with high liquid level,<12" below inlet(per Town Code §360-9.1) >keaching facility with standing liquid level at or above the invert pipe (per Town de §360-20 h) OTHER Repair deadline: WSEPTIMDEADLINES TO REPAIR FAILED SYSTEMS.doc Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a �. 37 Marston Avenue .nr Property Address Scott Smith CA Owner Owner's Na information is required for every Hyannis l m � Ma 02601 9/28/2016 t� page. City/Town State Zip Code Date of Inspection C71 �1 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 filling out forms A. General Information p on the computer, use only the tab 1. Inspector: key to move your cursor-do not Sean M. Jones use the return Name of Inspector key. S.M.Jones Title V Septic Inspection Company Name 74 Beldan Ln. AA Centerville Ma 02632 Cityrrown State Zip Code 774-248-4850 smjonestitle5@gmail.com SI4522 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 9/28/2016 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. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 37 Marston Avenue Property Address Scott Smith Owner Owner's Name information is required for every Hyannis Ma 02601 9/28/2016 page. Cityrrown 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: 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 w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 37 Marston Avenue Property Address Scott Smith Owner Owner's Name information is required for every Hyannis Ma 02601 9/28/2016 page. Cityrrown 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): ❑ i d stribution box is leveled or replaced El Y F1 N El 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 ' P t51ns•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 37 Marston Avenue Property Address Scott Smith Owner Owner's Name information is required for every Hyannis Ma 02601 9/28/2016 _ page. Cityrrown 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 '/day flow t5ins•3113 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 37 Marston Avenue Property Address Scott Smith Owner Owner's Name information is required for every Hyannis Ma 02601 9/28/2016 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- 1 0,000g pd. ® ❑ 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 16,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts 01 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M 37 Marston Avenue Property Address Scott Smith Owner Owner's Name information is required for every Hyannis Ma 02601 9/28/2016 _ 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 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 37 Marston Avenue Property Address Scott Smith Owner Owner's Name information is required for every Hyannis Ma 02601 9/28/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: 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)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons 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•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 37 Marston Avenue Property Address Scott Smith Owner Owner's Name information is required for every Hyannis. Ma 02601 9/28/2016 page. Cityrrown 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: 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 i Commonwealth of Massachusetts W Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w "r 37 Marston Avenue Property Address Scott Smith Owner Owner's Name information is required for every Hyannis Ma 02601 9/28/2016 page. CityrFown 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 7/16/97 per town records Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.5 feet Material of construction: ❑cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Joint were ok, no leaks, vented through the roof 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: 1500 gallons Sludge depth: 6" t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 37 Marston Avenue Property Address Scott Smith Owner Owners Name information is required for every Hyannis Ma 02601 9/28/2016 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 3" 31' Scum thickness Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? opened covers, took measurements 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 structurally sound, water level was ok at time of inspection but showed signs of past hydraulic overloading. tank should be pumped soon. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 37 Marston Avenue Property Address Scott Smith Owner Owner's Name information is required for every Hyannis Ma 02601 9/28/2016 _ page. CityrFown 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 ❑ 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 i Commonwealth of Massachusetts • Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 37 Marston Avenue Property Address Scott Smith Owner Owner's Name information is required for every Hyannis Ma 02601 9/28/2016 page. Cityrrown 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 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.): 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.): 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 u Title 5 Official Inspection Form b Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 37 Marston Avenue Property Address Scott Smith Owner Owner's Name information is required for every Hyannis Ma 02601 9/28/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2 ❑ 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 chambers were located and opened. chambers werefound to be full to the top resulting in a failing inspection. 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-3/13 Title 5 Official Inspection Forth: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 G M , 37 Marston Avenue Property Address Scott Smith Owner Owner's Name information is required for every Hyannis Ma 02601 9/28/2016 page. Citylrown 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 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 37 Marston Avenue Property Address Scott Smith Owner Owner's Name information is required for every Hyannis Ma 02601 9/28/2016 page. Citylrown 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 v v 2 - ( Z` A`Z 2 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 37 Marston Avenue Property Address Scott Smith Owner Owner's Name information is required for every Hyannis Ma 02601 9/28/2016 ___ 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: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record Y 9 If checked, date of design plan reviewed: 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: Groundwater elevation was not established. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments wM 37 Marston Avenue Property Address Scott Smith Owner Owner's Name information is required for every Hyannis Ma 02601 9/28/2016 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 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 VE Town of Barnstable P#_ 1,5['R)5 Department of Regulatory Services aunrtaztar Public Health Division Date id39 �� 200 Main Street,Hyannis MA 02601 Date Scheduled l 2 Time _ Fee Pd._ Sail Suitability ssessment for.,Sewage Dispos l Performed By: Witnessed By: LOCATION&.GENERAL INFORMATION Location Address ��J,A„'�r , '�.+� Owner's Name C/ ""�►' (�IVU��aLA� I / Address ✓�av►1 ' 'l Assessor's Map/Parcel: 7Q,� �� / Engineer's Name�• a""'1�" NEW CONSTRUCTION REPAIR Telephone# Land Use• Slopes(%) Surface Stones Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well ft Drainage Way ft Property Line ft Other ft SKETCH:(Street name,dimensions of lot,exact locati s of test holes&perc tests,locate wetlands in proximity to holes) W i Parent material(geologic) Depth to Bedrock Depth to Groundwater. Standing Water in Hole: !2 6 Weeping from Plt Foce Estimated Seasonal High Groundwater DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: Iff. Depth to soli mottles: jn. Depth to weeping from side of obs,hole: in, Oroundwn�Justment fr. Index We[14 JJ�"�Reading Date: �-30 ]ndex Weli level Adj,thctbr AcU,Groundwater Level, s PERCOLATION TEST Data Thne,.��, Observation: A Hole# Time at 9" Depth of Perc Time at 6" Start Pro-soak Time® I / Time(9"-6") End Pre-soak / v v Rate MinJlnch Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back---------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the. Barnstable Conservation Division at least one(1)week prior to beginning. Q:ISEPTIMERCFORM.DOC �-� VS DEEP.OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture .Sdil Color Sol] . Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,,Boulders. onsistency %t3ravel) D 1r,Q LAV ;001 0) Lip DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,% DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency. DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones',Boulders. Consistency. Flood Insurance Rate Map: Above 500 year flood boundary No— Yes Within 500 year boundary No ,Y'es Within 100 year flood boundary No,.V Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pery o material a exist in a l areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of' turally occurring pery ous material? Certification I certify that on (date)I have passed the soil evaluator examination approved by the Department of Enviro nen al Protection and that the above analysis was pe r d by me consistent with . the requ ed4 ining,ex rti a perience described in 10 CMR 15.017 Signature Date i b� :\SEPTICVERCFORM.DOC TOWN OF BARNSTABLE 1,04_rtLTION :3-2 1)14xs ry5 A SEWAGE # g VILLAGE AI S 92Rt ASSESSOR'S MAP & LOTAlP- 9 -00 'M INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) sa `ram �ize � NO. OF BEDROOMS BUILDER OR OWNER PERMIT DATE: 7- 5 — COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility S79 Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) P2,4 Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) l Feet Furnished by 10a ") 0 0. 3 Z ON � N t No. 77 Fee �J THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: es PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 0[ppYication for Miq;paar bpgtem Construction permit Application for a Permit to Construct( )Repair Upgrade( )Abandon( ) ❑Complete System El Individual Components Location Address or Lot o. �. 2_ 9— I'3� Owner's Name,Address and Tel.No. As_:r's"Map/Parcel O� IV Y In r�,N ,Address,and Tel.No. Designer's Name,Address and Tel.No. G� Type of Building: Dwelling No.of Bedrooms� Lot Size sq. ft. Garbage Grinder( ) 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 Nature of Repairs or terati ns(Answer when applicable) J� Date last inspected: Agreement: The undersigned agrees to ens construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions Title 5 f th nvironmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issue' by this d�of e h., Signed 1.— Date 7--1i&— j1/ Application Approved by Date Application Disapproved for the ollowing reasons Permit No. c Date Issued //�� ,,,,TOWN OF BARNSTABLE U/ LotAVON �� /'/<.SI11WU5 SEWAGE # _g 7 " 3- VILLAGE 4 ,4"y/y(S rCM e ASSESSOR'S MAP& LOT INSTALLER'S NAME&PHONE NO. )0 �� -0 lob SEPTIC TANK CAPACITY 1500 sn✓ LEACHING FACILITY: (type) �' — sod 1��iz-4 NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: 5 - 9 COMPLIANCE DATE: 7 / Separation.Distance Between the: Maximu.m..A usted Groundwater Table and 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) G Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet ofleaching facility) __l3�'r Feet Furnished by �/ /�a�ram✓ G t5oa 5� � � c= cs (y19R5- A)S A Utp 10 No. — 3 S a.. ~ Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION--TOWN OF BARNSTABLE., MASSACHUSETTS ZippYication for Migpogal *pgtem Construction Permit Application for a Permit to Construct( )Repair Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or of o. l- 1 ��- /3a Owner's Name,Address and Tel.No. x. Assessor's Map/Pazcecz� �/ W `t In Address,and Tel.No. \ Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flower gallons per day. Calculated daily flow °" gallons. Plan Date Number of sheets Revision Date Title Size of S ptic Tank �d d Type of .A.S. — U ,5/.. description o Soil Nature of, epairs or terat' ns(Answer when applicable) VW / v {. Date last inspected: ; t Agreement: The undersigned agrees to ensure-th construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions ofTitle 5 f th nviro mental Code and not to place the system in operation until a Certifi- c�te of ompliance has been issue by this d of e th. Sigll:ed �°'-�.." Date 7- ApplicationApproved1by ' ,._�-;f, + Date ' .; Application Disapproved for the ollowin reasons-,' Y Permit No. r:Ddte.dssued ———— ————— + THE COMMONWEALTH OF MASSACHUSETT BARNSTABLE, i S , MASSACHUSETTS a Certificate of Compliance 3 THIS IS TO CERTPY ty On-site Sewage Disposal System Constructed( )Repaired (A) Upgraded( ) Abandoned( )by at ?? has been constructed in accordance with the provisions of Title 5 and the for Disposal System Con Action Pe 't No. - dated Installer Designer. - The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date .rt Inspector 3--- - -- ------------------- -------� No. �Fee ' r _ THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE,, MASSACHUSETTS �Digpogal 6pgtem Construction Permit Permission is hereby anted to F.9nstruct Repair(k) pgrade( )Aba on( ) r System located 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 completed within three years of the date of this permit. _ Date' Approved by NOTICE This Form is to be"used f®r-the Repair of Failed Septic Systems Only_ • �« �� ,. r ',� ter .` ...,.,.. .... .a..ti•........ .,...,..,.,. ..w..��..R;ray:..:�..«�,W.._..�-..:•�w,..�,..,..__.:�...,. .�:...'�.ii::;.a..�\.:. .._....__ ..� _ ..... CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL; WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANSII.`-' OP,7/10 hereb that the application for disposal.,woI, Y certify rks + ..,.�, construction permit signed by me dated _'7� /Z" T , concerning the' property located at �� v Meets.-all of the P Y following criteria: a • There are no wetlands within-380"feet of the proposed septic system • There are no private wells within'150 feet of the proposed septic system - • The observed groundwater table is 14 feet or greater below the bottom of the leaching facility es • There is no increase in now and/or change in use proposed ' • There are no variances:requested or needed' - - d SIGNED: DATE: � � �— ��. LICENSED SE SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBEk [Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted]., ~ - - 4 J, f P t 1 gt R� s V� 8Z ----------------- O � � t COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS 3 DEPARTMENT OF ENVIRONMENTAL PROTECTION t TITLE 5 OFFICIAL INSPECTION.FORM-NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSALSYSTEM FORM PART A CERTIFICATION Property Address:. Owner's Name: ' EAR :EED Owner's Address: ' Date of Inspection: ��) ��Q,° LE Name of Inspect r: lease pr'nt). ° r *°ll Company Name: L' e-- m ^•;;.,. Mailing Address: (NAP Z a� 64 � Telephone Number: , PARCEL CERTIFICATION STATEMENT LOT 2 0 'Q 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 N eds Further Evaluation by the Local Approving Authority,. " F i I s 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 ofthe. DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Noted.Comments r ****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 ordifferent conditions of use. Title 5 Inspection Form 6/1.5/2000 page I Page 2 of I I OFFICIAL INSPECTION FORM—.NOT FOR VOLUNTARY ASSESSMENTS + SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: Date of Inspection: o Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: JI 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. i Comments: B. System Conditionally Passes: , np,or more system"components as described in the"Conditional Pass"section need to be replaced or repaired. The system, u,ponllcompletion of the replacement or repair, as approved by the Board of Health,will pass. . "•-'��.aaew.w;..ap:.A,.w.; ,r`«i aJ!1� . Answer yes,no or not determined(Y,N,ND)in the 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 exfltration or tank-failure is imminent. System will pass inspection if the existinoank is replaced with a.complying septic tank as'approved by the Board of Health. *. A metal septic tank will pass inspection.if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: 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'p8s inspection'if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system-required pumping more than-4 times a year due to broken or obstructed pipe(s).The system will pass.inspection if(with approval of the Board of Health):. broken pipe(s)are replaced obstruction is removed ND explain: . 2 Page 3 of 1'1 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner:Qka,� Date of Inspection: C. Further Evaluation is Required by the Board of Healthy 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 1.5.303(1)(b)that the system is not functioning in a manner Which.ivill_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 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 publicwater'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 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: 3 Page 4 of 11 OFFICIAL,INSPECTION FORM-.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFhCATION(continued) Property Address:., c?.7 r Owner: Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes . Nq� _ ��✓✓ 13ackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface dthe ground or surface waters due to an overloaded or, / clogged SAS or cesspool _ W 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 now V 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. ,f 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 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.) AO (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 Ilealth 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 16,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no 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 Department. 4 Page 5 of 1.1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART:B CHECKLIST Property Address: Owner Date of Inspection: p010 Check if the following have been done You must indicate"yes"or"no"as to each of the following Yes No 1 Pumping.information.was provided by the owner,occupant,or.Board of Health. f 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? V 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 o_f 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).pro.vided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption.System(SAS)op the site has been determined based on: Yes no Existing information.For example,a plan.at the Board of Health. Determined in the field(if any of the failure criteria related to Fart Cis at issue approximation:of distance is unacceptable)[310 CMR 15.302(3)(b)] 5 } Page_6 of I I OFFICIAL INSPECTION FORM=-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE'DISPOSAL SYSTEM INSPECTION:FORM PART C SYSTEM INFORMATION Property Address: `� A•,�r7d/1�i/� �� Owner:. Date of Inspection: /Q Q FLOW CONDITIONS RESIDENTIAL.` - Number of bedrooms(:design):-. Nurr ber of bedrooms(actual): . DESIGN flow based on 310,C,MR 15.203 (for example: 11:0 gpd x#of bedrooms):3 Number of current residents:1 Does residence have.a garbage grinder(yes or no); �— Is laundry on a separate sewage system (yes or no [if yes separate inspection required] Laundry system inspected(yes or no Seasonal use: (yes or no): �- Water meter readings, if available(last 2 years usage(gpd)): f— ew ioZ Sump pump(yes or o): --- /d. Last date of occupancy: V' Gft' COMMERCIAL/INDUSTRIAL Type of establishment: Desigri flow(based on 310 CMR.15.203): gpd Basis of design flow(seats%persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system'(yes or no):_ Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Sourceof iriformadon: Was system pumped as part of the inspecti n(yes o.: If yes,volume pumped: gallons--How was quantity pumped determined? Reason'for primping: . . 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) —Tight tank _Attach a eopy'of the DEP.,approval _VO/t}ier'(describe): p� GQ) rozimate age of al components,date installed(if.k own)an source o ormationel Weresewage'odors detected when arriving.at the site(yes or nc ; ,Q` Page 7 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE-DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION,.(continued) Property Address: Owner Date of Inspectlon: rlo� BUILDING SEWER(locate on site plane- Depth below grade: Materials of construction:_cast iron _40 PVC_other(explain): Distance from private water,supply well or suction line Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC.TANK: locate on site plan) i Depth below grade: 7 Material of construction:i/Concrete_metal_fiberglass_polyethylene other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: Sludge depth: lei' Distance from top of sludge to bottom of outlet tee.or baffle: Scum thickness: Distance from top of scum to top of outlet tee or baffle: y J Distance from bottom of scum to bottom of outlet tee or baffle: /0�� 10i+✓ How were dimensions determined: Comments(on pumping recommend ions,infet and outlet tee or baffle condition,structural integrity, liquid.levels as related to outlet invert,evidence of leakage,etc.): GREASE TRA {. cate on.site.plan) r Depth below grade: Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE-DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: TIGHT or HOLDING TANK (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass Uolyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of fast pumping- Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX 'if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box,etc.): PUMP CHAMBER (locate onsite plan) Pumps in working order(yes or no): Alarms in'working oi=der(yes or no): " Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY„ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION:FORM PART. C SYSTEM INFORMATION(continued) Property Address: _ Owner: 1131 Date of Inspection: "��ar, , 0O lan excavation not required) M (SAS):. locate on site 9 SOIL ABSORPTION SYSTE ( ) �,G'( P If SAS not located explain why: Type leaching—pits,number:_ ching 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 : JI CESSPOOLS: 1 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 or no): Comments(note condition of soil,.signs of hydraulic failure,-level of podding,condition of vegetation;etc.): PRIVY —(locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(not o signs f soil si of hydraulic failure, level of ponding,condition of vegetation,etc.): e condition 9. Page 10 of 11 OFFICIAL INSPECTION FORM-.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: w —,', (2�xc Owner: Date of lnspection: 0)Qoca SKETCH OF SEWAGE DISPOSAL.SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. l I 11 i i �t 9 ' 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 37 NOAV2a,r�.&e- A Owner: tv I Date of Inspection: Gc SITE EXAM. Slope Surface water Check cellar. Shallow wells Estimated depth to ground water /�'feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from.system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked.with local Board of Health-explain: hecked with local excavators, installers-(attach documentation) Accessed U.SGS database=explain: You must describe how you established the high ground water elevation: 11 Permit Number: Date: • Completed by:. 09!�Lt9 � HIGH GROUND-WATER LEVEL COMPUTATION Site Location: ( Lot No. O.wner:_ Address:. ��Q_° W,$ Q'111e, Contractor:—&-f `0144e 9 C®WJZ Address: Notes:- STEP. 1 . Measure depth.to.water table. `ft.. .......... .Date to nearest.1. 10 month/day/year STEP 2 Using.Water-Level.Range Zone and Index 61.1.-:M:a.p.locate site and determine: OAppro.priate.index well.................. ... kuigle OWater-level range zone.:...........:.............................:.......„{_:.: STEP;:3:. Using month ly.repo.rt.,"Current Water Resources Conditions" determine current depth to ®� jOz �y /water.level for index well ........................... . month/year STEP. 4. Using.Tabie.o.f•Water-Level Adjustments for index well (STEP 2A),.current depth' to water level for.index well (STEP 3):, and water-level zone (STEP•26) determine water-level adjustment ................................ ST.E,P; 5 Estimate depth to.high water by subtracting the water level adjustment.-(STEP 4) from measu.red-.depth to water l level at site (STEP'1) ................ Figure 1 1— eprDducible computation form. 15 cy". �. �,_ "��\ �.:: c cam. E--`� �` i ,II -�J�� ®:, q1 ' �. w L.-.�e....1 r. - �' :;:.. ,:. �. A �� trW u 5•. •ti (�� ` v\�. v\ a.� N i ¢.{ �'0 i S 3 � J °�I a� �� TOWN OF BARNSTABLE LOCATION 31 Mo►rsion A VE SEWAGE# ZOlL - 1401 VILLAGE H(40,nrn_ 'ASSESSOR'S MAP&PARCEL Z$$ 1130 INSTALLER'S NAME&PHONE NO. 6 )0A (41n - 01-53 SEPTIC TANK CAPACITY / p w LEACHING FACILITY:(type) r 5ior.c- (size) Z x ZZ X 6, NO.OF.BEDROOMS 3 OWNER PERMIT DATE: 4• )L COMPLIANCE DATE: a 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 Al -/6 $1 'y° 43-7M� � , AZ. Z3 ZA3EL BZ.y3'1, A II A3' Z$ ' y L33- Aw s O .By - z') AS'- 3Z � P_/c 3 85.- Z9 ' a L"OC&TION _ 5EWO,C4E PERMIT MO.__ IWSTQLLER 5 1JL1M ADDRESS ILDER 5 . t:11�1 AF- ADDRESS -DATE PERt�1T ISSUED �=2- 2 D AT-E COMPLI &MCE I.SSUE0 _ 4��-3-2-,:L . l I c 1 ,72 C--- I 1JJ/�1 No. ....... THE COMMONWEALTH OF MASSACHUSETTS _ BOARD OF HEALTH 1� ✓.n ....... .........OF..... .!�.....a.S.. .........................................../ Apphratinn -for Bi-qVuiitt1 Works Totu3tr7an amit Application is hereby made for a Permit to Construct ( ) or Repair ( dividual Sewage Disposal System at: d.R.. .l ...f_/--------------------•----- ---------------------------------------------._...__......-----------------------------------•-- LLcatio -Address '/ Lot.]yp/ IACA _.. . .1 �.? ....................................... 17 - -_SAS___.__.._ �xs_.l........................................... ----- -- - y Owner s r: Address --------- --------- --------------- --------- ----------------------------------- nstaller Address UType of Building Size Lot...........................Sq. feet Dwelling—No. of Bedrooms-----�-------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- Na. of persons---------------------------- Showers ( ) — Cafeteria ( ) f-4 Other fixtures ------------------------------------------------------ W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons. 9 Septic Tank—Liquid capacity------------gallons Length................ Width................ Diameter-----........... Depth---------------- xDisposal Trench—No- ____________________ Width.................... Total Length-------------------- Total leaching area--------------.-----sq. ft. Seepage Pit No..................... Diameter-------------------- Depth below inlet_.._................ Total leaching area...----:_.-_____--sq. ft. z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by-------- ----------------------------------------------------------------- Date---------------------------------------- a Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ fi, Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ 9 --------- 0 Description of Soil___ !. ---•--•--•----•------------•------•----•------------•-------•--•-------•---------------- -••------• ----- --------------------------- x U -----------------------------------------------------------------------=-----••------•--••-------•--------------------------------- -•-•-....-----------------•----•----•--............ . -- = L 60 �---------.,,_.._. U Nature of Re airs or Alterations—An wer wren applicable._... ,ls.11 �_ _l� --_�l!`.G ----------- - �' -`.d'-—--------------------------------------------------------- ------------------------------------------------------------ Agreement: , The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance witli the provisions of Article \I of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued y th o _of health. Sign Date Application Approved By-- -- ---------------------- ®.d''" - • �/�� Date Application Disapproved for the following reasons-------------------------------------------------------------------------------------•--•------------------------ ----•........................•--••••--------••------••---•--•-----------------•-•--•-----...------------.....---•--............._..-••---------_---•-•-_...-------------_...._.._----•------_._.....--•-- Date PermitNo......................................................... i Issued....................................................... Date 03 No.-•-•----�-.......�.... Fa$.,Z...a...0........ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Appliration -for Bi-qVviial Works Tomi#r7an rani# Application is hereby made for a Permit to Construct ( ) or Repair ( Individual Sewage Disposal System at: �/f --- ------------------------------------------------------•-----•--------------------------------•--. �Q L�catio Address L.ot lY� 4 v --- �� 1 / �-. Address Owner ..... - . --O a---- ---------- 1. h_-a........... ........ ..-----------••--•-•--------•---...................... Installer Address UType of Building Size Lot'__________________________Sq..feet Dwelling—No. of Bedrooms-----O--------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons_.__._..__.______________-__ Showers ( ) — Cafeteria ( ) WOther fixtures ----- ------------------------------•------------ W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons. W Septic Tank—Liquid capacity____-__-__gallons Length---------------- Width---------------- Diameter.........._____ Depth---------------- x Disposal Trench—No..................... Width.................... Total Length-------------------- Total leaching area--------------------sq. ft. Seepage Pit No____________________ Diameter-------------------- Depth below inlet.........-...._.____ Total leaching area------------------sq. ft. z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by--------------............................................................ Date--------------------------------------- Test Pit No. I________________minutes per inch Depth of "Kest Pit.................... Depth to ground water._-___-_.-__-____._.._.. f14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water__-__________-_.____.._. D x Description of Soil__- ---------------••---------•---•-•--------------------------------------•-----•-•----•-------. ------------------------------------------ -----------------------------_----------------------_-----------------------------------------------------------------------___ F ..................... __.-____------..✓• U Natur of pairS.,or 8Jteratjans—6pswer when applicable._..._�s�<��___-_ _/d __-______ !`e. ` S / [t--- I > sue- L Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issue y th o d of health. _ 7 Sign --- -- l ---------•-••-•---•--••---•--•--•-•---•--------•-•----- � ----�.. U Date _ Application Approved By-- -••-,,'_-------------- 7.5 Application Disapproved for the following reasons______________________ -•------------•------------------------•.......................•..-. Date--•--•---•-•-- ................................................................---------------•-•••-•••-----------------------•----------...................-----.-----•---•--•--------------.........•--------------- Date PermitNo. Issued........................................................ Date d THE COMMONWEALTH kF MASSACHUSETTS BOARD r1f HEAL Ij T ' ...............OF.......... .................... .................... �rrtilir �r �f f�nut�rli�t�rr TH IS TO RT That e Indi al Sewage Disposal System constructed ( ) or Repaired by.. ......Y -.----- . . ---•-•-•-•-•-•.. - --------------------------------------- Installer ...............•-- - --•------ has been installed in accordance with the provisions of KI I le XI of The State Sanitar Code as described in the application for Disposal Works Construction Permit �'`__/�,3 .................... dated_._.__`� .-.. ...1....... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY.DATE---��......... z -_.��s ------------------- Ins ector. ?__--- THE COMMONWEALTH OF MASSACHUSETTS S BOARD HEAL H ......................... FEE'-,:.............. Bispotittl or t AT ' ur#i> t r , 'it Permission is hereby grante --•- ---- --- --- _-- - -----•-- ---•- to Constr ct ( ) or Ir an Individual Sewa spos ystem 1 _ // treet / as shown on the application for Disposal Works Construction e it .._ _ ated_........................................ _ - �Jt3oard�of Healt /r DATE----...... ---------- ------ FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS 1 ASSESSORS MAP : S . PARCEL : � �� TEST HOLE LOG � I) 'I'he msluiIll ion shall calnp� with "I�itle V and 'fowls of�j"5rnru.�tluard ol. SOIL EVALUATOR :--Alp ,m" ✓'v I lealth IZegulatlons. FLOOD ZONE: — - - ---------- ---- WITNESS : I 2) 'I'lie installer shall verify the location of u(ililies, sewer inverts and septic REFERENCE: Ecor� i `e�(D. ) q ( DATE: bL�15- components prior to installation and setting; base elevations. �L� �] � $ PERCOLATION RATE: �-.2.'Nl�ll,�, 1 , 3) All glravity septic piping; to be 4 inch Sch �I1) I'VC at I/8" per fircrt. "I he lust two Icel onl of the d-box to the (caching shall be level. 4) "I'his plan is not to be utilized for property line determination nor any other Ile Upi TIi- I TH-2 purpose other than the proposed system ins(allation. t t7 10 t ✓ fA LoW t 5) All septic components must nreet'fille V specifications. l Ig1' l�j'' . 6) Parking shall not be constructed over I I10 septic components. 6q/ 7) The property is bounded by property corners and property lines. 8) The property owner shall review design considerations to approve of total LOCATION MAP Zoo' A1M 1 design flow and number of bedrooms to be considered for design. Receipt In t of payment for the plan and installation based on the plan shall be deemed approval of the design glow by the owner. q,p 9) The existing leaching or cesspools shall be pumped and filled with material � I/� 1l(r'�. 1 , 1 n 011 per Title V abandonment procedures. Those within the proposed SAS shall 'r\ V�l.l lJ l� _ 1 �j c� be removed along with contaminated soil and replaced wilh clean sand per _ ,, 2•✓ (7 (7 I'ide V specs. V+�� _ 'a (DF-0�t�-I� l20 -3 `� 3,8 go)System components to be 10 feet Irolit water line. Sewer !roes crossing (lie C� IV�LZ9 NDE�C �g water line shall be sleeved with 4 inch SCI 140 PVC with ends grouted if applicable. 'I'he proposed SAS is being installed below the water service --- line. 'fhc line is to be sleeved as aforementioned and maintained in place. S E P T i C SYSTEM DES I GN 1 I) If a garbage e g (grinder exists it is to be removed and is the res ponsibiIit he � y of t owner to ensure such. ESTIMATE ` 1? The installer is to take caution in excavation around the gas line ifsuch FLOW ) 6 t � exists. F:t=DR00MS AT GAL/DAY/BEDROOM - �'�1740 GAL/DAY 13)"fire iustalier shall verify the location, quantity and elevation of the sewer ", lines exiting (lie dwelling"rior to the installation. t� g l0 14)This plan is representative only that a system can lit on a property meeting ' rI� ��1W Il�� SEPTt C TANK I [ Y 6 'Title V rcc uirements. N ?j W GAL/DAY x 2 DAYS GAL _.:_ o USE I�O GALLON SEPT I C TANK � C1511�1cc� _ r _I-OZ.. Y. ,bb tZ - O SOIL� ABSORP�ION SYSTEM \ y � 5Fav1U - 1-1L'Q-51 �,,,�y�t�ur4t�ss� h / S I U-E� AREA: ��i �, .IG�1 . \ / C BOTTOM AREA: ' Z �i MASON IS7 v p No. 1066 a 4i SEPTIC SYSTEM SECTION ' D � I V b` mid O�il - 1 r C. _ _-_I 11, 7 ►Z , GAL 13,�� All _ .%1 r�,1 � EPT I C TANK i All 61 a is '' n� Ca>i.�• _.�__ ti of xN 10 YyG SITE AND SEWAGE P L A H 'p�� : I LOCATION : ' - ! )-JH L Pd2W'l,4 bti ' H il l 1 j VOKI PREPARED F 0 R : JA) Eo5 .1 . �_ i I � _ >� ,.�� w_x�, �s �� , tiw '�u' ^"�- SALE: ;►W. _- i _ w , V V t� DATE: •,^, D A V I D B . MASON S O N f� I I *� _ -- _ -- DBC ENV I RONMEN`TAL DESIGNS o� �► t, EAST SANDW I CI MA L' �' - DATE HEALTH AGENT ( 508 ) 833- 2177 --- i