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HomeMy WebLinkAbout0040 PRUDENCE LANE - Health 40 PRUDENCE LANE, COTUIT A= 040 053 i t� 9 s • w COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS ])ZPA1tTKZNT OF MMMONI[ NTAIL PROT$CTION 01 0 053 TITLE 5 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM ASSESSMENTS PART A !/� I CERTMCATION PMP"Address: d c' ►� c L /L� G- / Owner's Name Owner'sAddrms: i Date of Ind; c Name of hapector Company N ( Pam) y =w Mailing Address: o d �-G /V aS A r- TeJephaee Number. r� CERTMCATION STATEMENT ' T I that I have personally inspected the sewage&posal system at this address �g experience in as of the time of the ins ce at m.The inspecti�WN p approved system inspector paw �and emnoe aCon site sewage ems,I am a DEEP 7�-"13.3- of Title S(310 CMx 11000). The system; passes pan" sses Fails Pbrdw Evaluadon by the Local ins AWrity Inspector's Signature; -�� Data G -/,� OS Mw F.�sygein wfthm " CW of ft iron to the logs of B Antborily(Band of Han or ad or& �,the respect "&Vecd n•If the system is a ftW system or has a design flow of 10,000 system owner span submit me to f; and�ce of the DEP.The original shoald be sent to the system owner and copies serrt to the ' MWW&Y• g Notes and Commute report only describes con didoru T� st the time of inspeedon and under the condidons of use at that condidons o of time. n does rat address how the system will perform in the ft.under the same or ditl'erent f il ueam. • Page2af11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTMCATION(contim,4 Pk""Addn= 0 r�c'eh�e Z-,j/ Owner. G�,, p CA 6 3_5 Date of atsinctibuQ Check AAC,D or E/ALMAM complete an of Section D A. Sy5urpium. 1 have nd famd any mb=atka which of evalnatiod, 15.303 aria 310 CJWR 13.304 exist.Any faihn aitaria d in 310 C M theone>isiltu�epdbia elow Comments+ r:or Conditk napypasses:cOmPonerb �� as de�,•bed in the"Come per••�n . man the repiaoemeor as Med d alcoved by the Boar H be�Pass. Answer c0ainye4 no or not determined(Y,N,ND)"mat_far the following statemeftM*not deermbW p kM The septic tank is metal s and over 20 yeas old+or the septic tank(Whether metal or no)is stftwly *existing took is nephaced withwith oompiying tack asOr uftBdm or tank MM is Wmhm* will�°man if* f the meW septic teakwillpiss mspegien if it is strucpraily sonny not 1 �H 'indicating the the tank is leas thin 20 years old is avWl*k and if a Cartiflc ND ; o � Of Sawov backup or btftk out or bmimn,segled ar,m�,y�en gh sic water level is the box doe to be M or approval of Board of Health): box System willpam man if(with — broken s)am wed — obstractim removed d aft b Wm box is leveled or uplaced AID explain: -- The System required PIMOW Mont than 4 times a year dw to bra,=or Page�nspwdw if(with approval ti the Board of Hesltit): a P (s)• The system will bmk=Pq)e(s)ant Mlaced obstrncaon is removed ND explain; Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSES SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) psperty Addis d'r� c'evr<e `. �A, Owner. / C ®► r D O 3J Date of Inspedios; 7` C. Further Evahration is Required by the Board of Health. Caodidons exist which require fwthe evaluation by the Board of Health in order to is�g to P�public health,safty or the eavimmmlea amine if the system L s7�b stm ilPasN unless Board d ltlt Hea determines in aoeordamee wilt 310 CUR 13r303(1)(b)that the toning In a manner which wN Protect pubde health,safety and the eavirmment: _ Cesspool or privy 18 within 50 het of a s nAme water _ Ccssp001 or privy is within 30 feet of a bordering vegetated wetland or a salt marsh 2. Sysbem wM fail unless the Board of Health(and lPabVe Water Supphkr,if any)determines that the system Is thncdoning in a manner that protects the public heW*safety and environment. The system has a septic tank and sosl absoWdon system(SAS)and the SAS is within 100 feet of a surface water supply or td6utary to a snrihoe water ggVjy — The system has a septic tank and SAS and the SAS is within a Zama 1 of a public water supply, ._ The system has a septic tank and SAS and the SAS is within 30 feet of a private antes mWly well. P�water has a septa tank and SAS and the SAS is less thaw 100 Beet but 50 fat or more from a UP*well Method used to determine dista� '*Ns mlem lases if the well water analysis,ped+oamed at a DEP cer ificd bacteria ad volatile noOnrPeiar comhpoi u&10 that the well is free ft 9'for eohform awe A = equal w or less than 3 ppm,p Vvi&d ft off adached to this fiorm. 3. Other. • Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(contiimmo Property Address: 0 rvr 411ceo a C3 Owner. C a Date of lagwxdo ; /j- A System Failure Criteria applicable to an systems: You indicstte`�,�"or"no"to each of the fono for wuig moons Yea No of sewage into&d ty or"M due to maloaded or d -= or pondm8 of efilued to the o8t SA3 or cesspool sur�oe of the Wound or surface waters due to an averl0aded or LG Hqqid kvd in dw deb gm box above artist invert doe to an ° one or clogged SAS at AV&in ceaWd is less thaw 6"below juvft in the l g moue than 4 times ast of available����than�'(by flow' Yew MMdue to dogrel or p4Ws).Number Of f�° Pdw�°d�widdu ��.a dbm water elevatiion of a sudaoe wateryof hibutaryto a s�faoe p xd m of a oesepod or pm►Y is within a Zone 1 of a public well. gxution of a cesspool or p h7 is within 50 ft of a p hm a water well dL �cesspool of than 100$et but ��Sam a private water per*wel at a M a o gftb d quality�& [Z'�Vim.P�If the well water analysis,laboratory,for coefam bacterh and volatile o lndicatm that the wee is fru front �k compounds Prom first that faceity and the premenee nfbvm and nihwh it equal to or leas than S ppm,ProWded of amnia are no��A ropy of the aaal3+ds most be attached to thL form.] o�faeare ciiaeaia (Yea/No)The system fdii,I have,dmcn'bed in 310 CMS R 15.303,therefore the one or mom of the shave failure s mg as Health to determine what will be necessary to com xt the fail owner shouM contact the Board of & Large Sysi ms: To be considered a large systm the system mut"m a f ad. adety with a fbw of 10,000 gpd to ISM You must indicate either'"or`ne to each of the 8ollowiw (Z'Le f° Cdft=VY to large gmma in adMon to the afteris above) Y no system is within 400 fed of a sord"d mi*g water sul#y �-- the system is within 200 feet of a tnbutmy to a surface drinking water sup* the system is located is a MftM sensitive Zone II of a public water supply wen area(dim Wellhead Ptntecaon Area—IWPA)or a mapped If yom have "Ye8"to MY queabi0n in Section E the system is Considered "Yes"m Section D above the large system Las faded The owner or a�� or d aired significant threat under Section E 0r failed �,n undec SeD shall 0t of any large system considered a 15.304.The system owner should contact the appropriate reSkmal og�Depmtmatwith 310.CUR Page 3 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST PrWrty Address: �� 4ile-6? L Owns: r o Date ati Inapectio.: �i /f 0 Check if the following have bow done.You must i xkft es"Of"no"as to each of the folio ' Y� Pumping mfomat m was povxbd by the owner,oocup®nt,or Board of Health _ — were any of the system convonents pumpd out in the previons two weeks 4zfHw the system umved normal am m the Pmvhm two week prod :J� IRW V0101005 of we*been i0hado ed to the systmn neoently of as part of thishLqpeCtj= lNer+e as built plans of the system.obtained and examinee(If they were not available note as N/A) Vas the facility or dwelling inspected for of srgos sewage bad up Was do site inspected for signs of berate out —z-f Were all system Components,poduding the SA$,locntect on site w "the SeFdc od,tank manholes opened,and the of the tank afthe at tray material afoot, �of ngzK depm of '�for the condition sledge mddepth of scam of — s the ba q owner(aed oom wft if dim fr+ mma p led with iaforma as the proper e aft se,� vyskms. The sbe and bcabbs of the Soil Absorption System on the '(� sue has been determined based on: Yes `/— ..F�cmmpk a plan at the Board ofHealth• Dcleis�) � Bell(3 any of the fullers Criteria related to Part Cis at issue VW)dIn2dan of distance ••. 1.10ge6ofII OFFICIAL INSPECTION FORAM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACY SEWAGE DISPOSAL SYSTEM INSPECTION,FORM PART C SYSTEM IleIFOIiMATION. Property Address: 14 Nth, e Owner: r C e Ito Date of Lrapecdose 6 , IDl� TUL W COND3T14ON8 Number of bedrooms(gip)- -L Nmber cf be�(actual}. .3 nESKTT ao�►based.oa:•3 l0 CdbIIt•1,5,203(� E lu gta:�R of boanaomsr .3 30 Number of cumt Does residence have a P ftp grinder bu or no): D laundry on a se wACsewspUs=bu or no):tie [if yes separate *)DW=required] Laundry system arspected(qea or no): If-V Seasonal use:6 or no): /✓o �Pip if �2 you (tin): Last date of occmpans . c►•� CO1rIlURCUMNDUSMAL 7'Pe of establis>imat- Design floe►(based on 310 C'MR 15.203): A)d. Basis of doWSn How(scaftVpefsons1sqk tc.).* Grease ftv pesent c^es or no):Indusbial — woo 5tank 1 (yea orno):— Ncn-sue►waste dbcbmW to the TSde S system(yes or no):Water readiam _ Last date of .if nad*k. occ�rp�/usa OT=R(dead,): pumping Records GZMULAL EMj MA7WN Wsource of i ic®: dl 4� A'la, / j as p as pant of the bqmdm(ym or Be).—4�/ myek nvolunme P �---Pam ms—HOW was qum tkY pmmped deemminee —Septic tank man box,soft absorption system —Sio&cesspool —overnow cesspool --Slaired (Tea or no)(if yea,attach previous bqxWm moor*if any) okame t)e�nologs►•Attach a copy of the cormat operatic and � d(to be —Titk tank _Attach a copy of the DEP approval —Odm r(desmft): Approximate age of all cOwPoneaK doe imaalied(if]mown)and source mixnrabon: Were sewage odors detected when arriving at the site(yes or no):Lf/b Fagie 7 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY AME!%UCM SUBSURFACE SEWAGE,DISFOUL SYSTEM INSP PART C 'ION FORM /�_ SYSTEM INFORMATION Property Add„ `T 0 o re C O U Date or Inspecdm BUILDING SEWER 1locate on site Jim) Mateaials of cam _ km Commeobs(an c[ amply wen 4 sactioss i -CW SEPTIC TANX- 00caft-on site ) Depth below Sr dw(mataid ,, _.«mac -- lftankis m ale:_ bar a Uy'a C°aop''aooe(yes ae no)*'_;(attach a copy of Diumnamw X � es*of to bottom of abet tw-or baffie: o2 6 9 02 Distance from top of scAm.to �i �P of outlet tee or bWHr Distance from bottom cf scm to bottom of outlet tee ac bad, "' How wee deternhW& /e Comments QL � (on Pumping men ans,inlet and outlet tee CW as to o»tl�invert,evicieaoe of ,); cow dal integrih'; levels � �` r-► yr o� /'I.ee� c� A v G►y' �-yrs .� GREASE TRAP os site per) Depth below Material of eonstrnc60M. a meal Scorn tbickn Disum from top of x m�to top d outlet tee or bate: Date 1�b�0f�to bottom°f o°f tec or baf Pig as zelated tou pURPugreco'"Inendadook ink�°utlet te as baffle mve�Mdeace of abM CW) Wn"co,SMpnaLae , hqwd levels Page 8 of 11 OFFICIAL INSPECTION FORM=NOT FOR VOIXNTARY ASSL"� N'TS SUBSURFACE SEWAGE-DE9K"L SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(contimo4 Property Adarvm �N p,> 6 3 Ow,lr: ! C Oz.-l p Date of Io pedialt TIGHT or HOLDING TANK:/t (tom must bePtwmPW at Wne of m on)0ocate on site Dian) Depth below glade: Material of conmecdw M=m metal 9 � lens 0AWexp1ain): Dtm ; PROW Design Flow: ~day Alarm peseot(Yes or no): Alarm kvd: Alarm in waking order(Ye8 or no): Date of last pumping Comments(coition of alarm and fiod switches,etc.): DISTRIBUTION DO%: Cif WNW nmot be openedXlocate on site per) Depth of hqmd kvd abase outlet invert: `1 D t/-z a �-- Commeds(note ifboor in kvd and to q equA any e�deace�sdids leakage' of out of bow ); cwyom,any mdenoe of PUMP DER:_L Amite on site plan)) Paulp in waddog ardor(yes or no): Ahm in Comum"(oo&m ofpo no): ,oondifam afpumpe and appatmancM etc): Pa8e9afil OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEW- AGE-DISPOUL SYSUM Ii PEON FORM Vic. '' SYSTEM (amtkmo Owner.PropertyAAdmw ��C o p Dace of bgmcdm SOII.ABSORn7Ql1 SYS'f (SAS. . e�ait�Pam,ancavadw a".foOkw0 If SAS not locatid 0,1 illy. Type kWh*ftubm SWAM k—mok Adkf4 k a,amee S ►`� oR cftw cesspool,amber • Ty►Pdnamc of teclmolW Co mmem(Aate ;• of anal,signs of kkkau is level of ponding, ,, Ild P1,oaaion of a s , . �A ti rG• i CESSPOOM raft be pm'l'0d as Pon afmspe:fm)(ioaoe oa site plan) M m*a =d= . Depth sa door mld ' Depth arscmb Dhnmskso afoempo* Indcation Ind ofpou&&com"WafvqFbdM eat PB1Vlt:17/�enQ�e� daom�actian; Dimeafom Depth of sobi& Comments(noiecondi ofo s*sgo of c ,laud GfPmxm&cmdbm aa;vet )-. Par loaf 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENT& SUBSURFACE SEWAGE DISPOSAI.SYSTEM INSPECTION FORM PART C SYSTEM DWORMAT10N 4� Owner. c 6 p Date of hmpecdoas SIZTCH ff SEWAGtDZ9P0 pl SYSTM NOW*a*ct&of fhe sewage disposal system whaling ties fo at least two sup .Locate abenchffmllwells within lot)feet,Locate whet p�water ply the� of O [4 R � rGv _ -rode _ �2 3 ,Q &f�o�✓ I / d 1 3 s 93- 6 Pap 11 a[I 1 n I � OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Owner: s01 C ®�6 I?-fz Date at lespedion; �s �S srra KXAM SlopeSurface ma ta 0 3 Check cow S1aflow wdb 30 Esftm to p�aaad water f� C � � �ati� 33 Please indica6e(check)an MOMO&used to det mgne&e hioSmmd way deem: � 1�a�a n�aoed-If 6hes�die� i� site(des p%My/abomatim hata within 150 fw of S U) F Checbd with 10W Aoocnscd USGS databa "=pWx. ( won) You mast p�ue �yy,le"y �� �blo,®�aaad w1:57sZdr h14 i.. � D 7r Ci'ro © o C2 o (oo � !( � 00L9 IV/ �� f• • = ..: - CONI.1ON�trEAI,TH OF hLkSSACHt:SETTS - EXECUTIVE OFFICE OF EvVIRONMENTAL t1FF:�II; - = DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE tt'INTER STREET. BOS T ON \1A 02106 t61 TRUDYCOX- Secretar. ARGEO P tL CELLL'CCI DAVID B.STRL'HS Commiss:aae: Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: UO.INCR�`'N Narne of Owner Address of Owner: c Date of inspection: W// Name of Inspector:(PI ase Prirrt)H•C.h a I wn a DEP approved system inspector pvrumm to Section 15.340 of T'rtfe 5(310 CMR 15.0001 ComPanyxame: 4&CA �r'c Pk y.,'rr— a Ull,ittg Atfdress: rn .e., L mac,. f-� Kp�t_ �� =12-C4- cl Talephorte CERTIFICATION STATEMENT t I Certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true accurate and complete as_of the time of inspection. The inspection was performed based on my training and:.elcperience in the:proper function and mamtenance'of on-site sewage disposal systems. The system -;, s � Passes _ Conditionally Passes _ Needs Further Evaluati y Local Approving Authority B F 'Is jl Date: � Inspectors Signatarra The System Inspector shall submit.a copy of this inspection report to the Approving.Authority(Board of Health or;DEP)within thirty (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 s14 submit-the.report to the appropriate regional office of the Department of Environmental Protection. Tha original sfiould be sent to ttte system owner and copies sent to the buyer,if applicable, and the approving authority. NOTES AND COMMENTS I � � a to /` y �O 0 JAW . Z � revised 9/2/98 Page IofII WO Pled on Recycled Paper i - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) 'roperty Address: Jwner: Date of Inspection: INSPECTION SUMMARY: Check A, B, C,,or D: A. SYSTEM PASSES: I have not found any information which-indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure '—'—� criteria not evaluated are indicated below. COMMENTS: B. SYSTEM CONDITIONALLY PASSES: One or more system components as described in by'Conditional diti Board Pass" s"section need pas to be replaced or repaired. The system, upon completion of the replacement or repair, as approved . Indicate yes. no,or not determined (Y. N, or NO). Describe basis of determination in all instances. If 'not determined-,explain why not. _ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached) indicating that the tank was installed within twenty(201 years prior to the date of the inspection; or the septic tank, whether o1r not metal,is cracked,structurally unsound, shows substantial infiltration's exfihratick or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. _ Sewage backup or breako i ut or high static water level observed in the distribution box Is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). r broke n,pipe(s) are replaced obstruction is removed distribution box:is levelled or replaced The system required pumping more than four times.4 year,due to broken or,obstructed pipets).The system will pass inspection if(with approval of the Board of Health): broken pipets) are replaced obstruction is removed i ! Iw J I,fr 4 revised 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to date ine if the aystem is-failing to protect the public health, safety and the environment. 11 SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN•A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH D SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a aft marsh. 21 SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBUC WA SUPPLER,IF A MY)01:TERMjNES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH D SAFETY AND THE ENVIRONMENT: _ The system has a septic tank and soil absorption system( 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 soil absorption system. the„SAS is within a Zone t of a public water supply well. The system has a septic tank and soil absorption system nd the SAS, within 50 feet of a private water4supply well. _ The Sys.tem has aseptic tank and soil absorption systs and the.SAS,Is,less than 100 feet but.60 feet or more from a private water supply well,unless it well water analysis eoliform bacter and volatBe dij&k laompounds indicates that the well is free from ponution from that facility and the .pr sence of ammonia nitrogen and`Atrate rtttrogen is equal to or Mess than 5 ppm. Method used to determine distance (approximation not va6dL 3) OTHER - revised 9/2/98 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Addr ss: Owner: Date of Inspecti D. SYSTEM FAI S: You must indicate 'ther "Yes" or -No" to each of the following: I have dete mined that one or more of the following failure conditions exist as described in 31t CMR 15.303. The basis for this determinati is identified below. The Board of Health should be contacted to determine what will be necessary to corre_: the failure Yes No SAS or cesspool. _ Backu of sewage into facility or system component due to an overloaded or clogged to the surface of the ground or surface waters due to an overloaded or clogged SAS or pischarg or ponding of effluent _ cesspool. _ Static liquid vel in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. _ Liquid depth in sspool is less than 6" below invert or available volume is less than 112 day flow. _ Required pumping ore than 4 times in the last year NOT due to clogged or obstructed pipe(si. t Number of times pu ped _ spool or privy is below the high groundwater elevation. Any portion of the Sol Absorption System, ces _ y is within 100 feet of a surface water supply or tributary to a surface water supply Any portion of a cesspoo or priv . _ Any portion of a cesspool o privy is within a Zone I of a public well. _ Any portion of a cesspool or p ivy is within 50 feet of a private water supply wall. r • _ is less-than 100 feet but greater than So feet from a private water supply well with no Any portion of a cesspool or pri s. If the well has been analyzed to be acceptable. attach copy of well water analysis for acceptable water quality analysi coliform bacteria. volatile organic c mpounds.ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: You must indicate either 'Yes" or 'No- large systems of the ei f oil ion to the criteria above: The following criteria apply to r 9e The system serves s facility with a design flow of 10 00 gpd or greater(Large System) and the system is a significant threat to public health and safety and the environment because one or ore of the following conditions exist: Yes No _ the system is within 400 feet of a surface drinkin water supply _ the system is within 200 feet of a tributary to a sur ce drinking water supply _ the system is located in a nitrogen sensitive area(Into Wellhead Protection Area•IWPA)or a mapped Zone 11 of a public water supply well) The owner or operator of any such system shall upgrade the system in accor nce with 310 CMR 15.304(2). Please consult the local regionai office of the Department for further information. revised 9/2/98 Page 4ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: "iO P�w Owner: 4Y Date of Inspection: Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and•the system has been-receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this. inspection. As built plans have been obtained and examined. Note if they are not available with N:A. k _ The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow.; The site was inspected for signs of breakout. f yk All system components,excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees. material of construction, dimensions,depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: Existing information. For example. Plan at B.O.H. _ _ Determined in the field lit any of the failure criteria related to Part C is at issue, approximation of distance.if unacceptable) 115.302(3)(b)1, The facility owner land occupants,if different from owner)were provided wwith infoimati6h.on the prop atj"ntenaac&-of SubSurface Disposal Systems. revised 9/2/98 P+erSof11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORK. PART C SYSTEM INFORMATION 'roperty Address: 4o t aAE1UU—, Owner: Date of Inspection: . FLOW CONDITIONS RESIDENTIAL: Design flow: g.p.d./bedroom. Number of bedrooms (desn):,QL.,, �2 Number of bedrooms (actuafl: Total DESIGN flow_ Number of current residents: Garbage grinder(yes or no):�f Laundry(separate system) U&s or no):t-) : If yes, separate inspection required Laundry system inspected or no) Seasonal use (yes or no►: (— dlVt1`f�4niC y�IPt� g Water meter readings.if available (last two year's usage tgPdl Sump Pump (yes or no):� Last date of occupancy:V=%Q 0 1 COMMERCIALANDUSTRIAL: Type of establishment: gad 1 Based on 15.2031 Design flow: Basis of design flow 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: Lest date of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION r � PUMPING RECORDS and source of information: System pumped as part of in pectian:(yes r nol if yes, volume pumped: gallons Reason for pumping: T1(�E 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) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed(if known)and source of information: Sewage odors detected when arriving at the site: (yes or no)_tNtD revised 9/2/98 Page 6ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C L, SYSTEM INFORMATION(continued) 'roperty Address: Owner: Date of Inspection: BUILDING SEWER: (Locate on site plan) L Depth below grade: Material of construction:_cast iron)�140 PVC_other (explain') Distance from(rivate water supply well or suction lined Diameter _ Comments: (condition of joints, venting, evidence of leakage,etc.) SEPTIC TANK: (locate on site p an) Depth below grader Material of construction: concrete_metal_Fiberglass _Polyethylene_other(explain) If tank is metal,list age_ Is age confirmed by Certificate of Compliance_(Yes/No) t Dimensions: 1000$fW k - Sludge depth: - Distance from top of sludgeto bottom of outlet tee or baffler Scum thickness:_ cZ Distance from top of scum to top of outlet tee or baffle:__ Distance from bottom of scum to bottom of outlet tee or baffle: _ How dimensions were determined: A AQ04 2.&aA ' r , :omments: , structur integrity. (recommendation for pumping, condition of inlet and outlet tees orCbaffles, depth of liquid level in rela • n to outlet* v evidence of leakage,etc.) T O GREASE TRAP: pocate on site plan) 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: (recommendation for pumping, condition of Inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,etc.) revised 9/2/98 Page l°Ill SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C �( SYSTEM INFORMATION (continued) Iroperry Address: d Owner: Date of Inspection: I TIGHT OR HOLDING TANK: "L(Tank must be pumped prior to, or at time of, inspection) (locate on site plan) Depth below grade:_ _concrete _metal_Fiberglass _Polyethylene _other(explain) Material of construction: Dimensions: Capacity:_gallons Design flow:_gallons/day, Alarm present Alarm level: Alarm in working order:Yes _ No_ Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:�i (locate on site plan) Depth of liquid level above outlet invert: C "�d v — g-1V`�^�', _ r 1 •- Comments: (not if Lev _ nd distribution is equal, evide ce o solids carryover, evidence of leakage int rout of box, etc.) µ PUMP CHAMBER: (locate on site plan Pumps in working order:(Yes or No) Alarms in working order(Yes or No) Comments: (note condition of pump chamber,-condition of pumps and appurtenances.etc.) i revised 9/2/98 P.gcsorII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C �( Q(��}-�P/[ro SYSTEM INFORMATION (contir+ued) 'roperty Address: " tv `�'^'�"` — Owner: Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): J (locate on site plan, if possible; excav tion not required. location maybe approximated by non-intrusive methods) If not located, explain: Type: L leaching pits. number:- 1 leaching chambers number:_ leaching galleries, number:_ leaching trenches. number, length: leaching fields, number, dimensions: overflow cesspool, number:_ Alternative system: Name of Technology Comments: � k (note condition of soil. 'gns of hydraulic failure, level of ponding, d R sor on ' 'on of vegetati etc.) c>t O� CESSPOOLS: (locate on site plan) Number and configuration: Depth top of liquid to inlet invert: Oepth of solids layer: r h of scum layer: er:Y Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as pan of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY:=v (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condtion of vegetation, etc.) revised 9/2/98 Page 9of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM d i PART C SYSTEM INFORMATION (continued) property Address: Jwner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks Locate all wells within 100' (locate where public water supply comes into house) • 30 - L �y ���5v'� �3� 351 • revised 9/2/98 pAgetoorII • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (contirwed) toperty Address: Peol- wc� Owner: Date of Inspection: NRCS Report name --- Soil Type_ — - Typical depth to groundwater_ __ USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope No Surface water Check Cellar - Shallow wells ,-fIC Estimated Depth to Groundwater-u7 Feet Please indicate all the methods used to determine High Groundwater Elevation: - f Obtained from Design Plans on record Observed Site (Abutting property. observation hole. basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps r � Checked pumping records Checked local excavators, installers ' Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) v`s j, �,o���V Sv av � � �$1 l ��•CtN� bt�c a- 6�Z revised 9/2/98 Page 11of11 BORTOLOTTI CONSTRUCTION, INC. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Address Prop Date of lnspec} Map arcel --— Owner /0// / PART A — CHECKLIST 7 - CHECK IF THE FOLLOWING HAVE BEEN DONE: aD PUMPING INFORMATION WAS REQUESTED OF THE OWNER,OCCUPANT,AND BOARD OF HEA OCT 13 1995 NONE OF THE SYSTEM COMPONENTS HAVE BEEN PUMPED FOR AT LEAST TWO WEEKS AND T YSTEM'�Ad @! RECEIVING NORMAL FLOW RATES DURING THAT PERIOD. LARGE COLUMES OF WATER HAVE N EN INTMbWED INTO THE SYSTEM RECENTLY OR AS PART OF THIS INSPECTION. AS—BUILT PLANS HAVE BEEN OBTAINED AND EXAMINED. NOTE IF THEY ARE NOT AVAILABLE WITH N THE FACILITY OR DWELLING WAS INSPECTED FOR SIGNS OF SEWAGE BACK—UP. v THE SITE WAS INSPECTED FOR SIGNS OF BREAKOUT. r-' ALL SYSTEM COMPONENTS,EXCLUDING THE SAS,HAVE BEEN LOCATED ON THE SITE. _THE SEPTIC TANK MANHOLES WERE UNCOVERED,OPENED,AND THE INTERIOR OF THE SEPTIC TANK WAS INSPECTED FOR CONDITION OF BAFFLES OR TEES,MATERIAL OF CONSTRUCTION,DIMENSIONS,DEPTH OF LIQUID,DEPTH OF SLUDGE, DEPTH OF SCUM. L_ THE SIZE AND LOCATION OF THE SAS ON THE SITE HAS BEEN DETERMINED BASED ON EXISTING INFORMATION OR APPROXIMATED BY NON-INTRUSIVE METHODS. G � THE FACILITY OWNER(AND OCCUPANTS,IF DIFFERENT FROM OWNER)WERE PROVIDED WITH INFORMATION ON THE PROPER MAINTENANCE OF SSDS. PART B — SYSTEM INFORMATION RESIDENTIAL FLOW CONDITIONS \ � -- V No of Bedrooms No of Current Residents �j Garbage Grinder e 5 Laundry Connected to System -- -116 Seasonal Use NON RESIDENTIAL: ------ -- Calculatedflow) WATER METER READINGS,IF AVAILABLE: ----- Pumpi g Records nd Source of Information: GALLONS SYSTEM PUMPED AS PART OF INSPECTION? IF YES,VOLUME PUMPED = GALS Reason for Pumping: TYPE OF S EM: I Septic tank/distribution box/soil absorption system - - Single Cesspool _ Overflow Cesspool _ Privy Shared system (if yes, attach previous inspection records, if any) Other ex lain ( p ) Appr ximate age of all components. Date installed,if known. Source of infor tion. G/ne -� � �'"eL/ < SEWAGE ODORS DETECTED WHEN ARRIVING AT THE SITE?/" SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B — SYSTEM INFORMATION (Continued) SEPTIC TANK: Depth below grade: Dimensions: , Material of construction: _j,..- oncrete Metal FRP Other} Sludge Depth // Distance from top of sludge to y/�tom of outlet tee or baffle Scum Thickness -f Distance from Top of Scum to toR of outlet tee or baffle a - Distance from bottom of Scum to bottom of outlet tee or baffle Comments: l::�1115 --64 f CS - j /. Glade. Iv- r / 8 �mYA DISTRIBUTIONR BOX: Q/ �9 DEPTH OF LIQUID LEVEL ABOVE OUTLET INVERT Comments: Z�h az, PUMP CHAMBER: Pumps in working order? Comments: SOIL ABSORPTION SYSTEM SAS IF NOT PRESENT,EXPLAIN: TYPE: �— omments: Q LICZ CESSPOOLS: d Number and configuration Depth—top of liquid to inlet invert Depth.of solids layer Depth of scum layer Dimension of cesspool Materials of construction Indication of groundwater inflow(cesspool must be pumped) Comments: PRIVY: Materials construction Dimensions Depth of solids Comments: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM r PART B — SYSTEM INFORMATION (Continued) . SKETCH OF SEWAGE DISPOSAL SYSTEM: INCLUDE TIES TO AT LEAST TWO PERMANENT REFERENCES,LANDMARKS OR BENCHMARKS. LOCATE ALL WELLS WITHIN 100' 4S Jj 1 , 0 DEPTH TO GROUNDWATER: z vDEPTH TO GROUNDWATER METHOD OF DETERMINATION OR APPROXIMATION: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.0 — FAILURE CRITERIA (Indicate Y-yes N-no ND—not determined.Describe basis of determination.If"not determined",explain why not.) Al Backup of Sewage into Facility? Discharge or ponding of effluent to the surface of the ground or surface waters? t� Static liquid level in the districution box above outlet invert? 'v Liquid depth in cesspool, 6"below invert or available volume, 1/2 day flow? Required pumping 4 times or more in the last year? Number of times pumped Septic tank is metal?cracked?structurally unsound?substantial infiltration?substantial exfiltration? tank failure imminent? /4/ Is any portion of the SAS,cesspool or privy, below the high groundwater elevation? IV Within 50 feet of a surface water? Within 100 feet of a surface water supply or tributary to a surface water supply? j Within a Zone I of a public well? Within 50 feet of a private water supply well? Within 50 feet of a bordering vegetated wetland or salt marsh (cesspools&privies only, not the SAS)? A _ Less than 100 feet but.greater than 50 feet from a private water supply well with no acceptable water quality analysis? If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,amonia nitrogen and nitrate nitrogen. PART D — CERTIFICATION �;INSPECTOR: . ROBERT J. BORTOLOTTI ADDRESS: 765 WAKEBY ROAD, MARSTONS MILLS COMPANY: BORTOLOTTI CONSTRUCTION INC. MA 02648 (508) 771-9399 11 CERTIFICATION STATEMENT i I CERTIFY THAT I HAVE PERSONALLY INSPECTED THE SEWAGE DISPOSAL SYSTEM AT THIS ADDRESS AND THAT THE INFORMATION REPORTED IS TRUE,ACCURATE AND COMPLETE AS OF THE TIME OF INSPECTION. THE INSPECTION WAS PERFORMED AND ANY 1 RECOMMENDATION REGARDING UPGRADE,MAINTENANCE AND REPAIR ARE CONSISTENT WITH MY TRAINING AND EXPERIENCE IN THE PROPER FUNCTION AND MAINTENANCE OF ON—SITE SEWAGE DISPOSAL SYSTEMS. CHECK ONE: V�IHAVE NOT FOUND ANY INFORMATION WHICH INDICATES THAT THE SYSTEM FAILS TO ADEQUATELY PROTECT PUBLIC HEALTH OR THE ENVIRONMENT AS DEFINED IN 310 CMF 15.303. ANY FAILURE CRITERIA NOT EVALUATED AREAS STATED IN THE"FAILURE CRITERIA"SECTION OF THIS FORM. I HAVE DETERMINED THAT THE SYSTEM FAILS TO PROTECT PUBLIC HEALTH AND THE ENVIRONMENT AS DEFINED IN 310 CMR 15.303. THE BASIS FOR THIS DETERMINATION IS PROVIDED IN THE"FAILURE CRITERIA"SECTION OF THIS FORM. INSPECTOR'S SIGNATURE: DATE: ORIGINAL TO SYSTEM OWNER,COPIES:BUYER(if applicable),APPROVING AUTHORITY % No.--- = '„� Fps...... .. THE COMMONWEALTH OF MASSACHUSETTS yr-- BOAR® OF HEALTH / O F........... Appliration for Diivu. i al Works C untitrur#ion rmnit Application is hereby made for a Permit to Construct' ( ) or Repair ( ) an Individual Sewage Disposal System at: ....... _._.. ... u._, ...Uk/A_-�..... -------- --------------------------------------------------------- Location-Address or Lot No. C----- ------------------------------------------=----•---.._._..._..._..•------------._._...------------ Owner 4 ` Address r EL _ --------------- ----------------- --------------------------------------•_-- Installer Address UType of Building Size Lot............................Sq. feet �., Dwelling—No. of Bedrooms__._ SFr__............_-----Expansion Attic ( ) Garbage Grinder ( ) Other—Type,of Building No. of persons____________________________ Showers — Cafeteria Other fixtures .......---------•-••-•-••-•---- - -------------------------------------- ------------ . w Design Flow............................................gallons per person per day. Total daily flow..__._.__2_2_�'°.....................gallons. WSeptic Tank—Liquid capacity_! _gallons Length._:.°:(a..__ Width__:.......... Diameter________________ Depth.......... x Disposal Trench—No_.................... Width.................... Total Length.................... Total leaching area____________________sq. ft. - r Seepage Pit No........1------------ Diameter____-_-A._....... p ow inlet...... Total leaching area_ ,'r__9____sq. ft.Depth below Z Other Distribution box (V) Dosing tank ( ) 'J SE +7 &x(v r-eActi p i T" w I -L' of s-resdF- aPercolation Test Results Performed &V-5__ Date....!a...l_3:49�Ae_�___-... Test Pit No. 1:_e_Z_---minutes per inch Depth of Test Pit-----!_ ......... Depth to ground ri, Test Pit No. 2__'-_z-___minutes per inch Depth of Test Pit-----L_�-........ Depth to ground water.......... .............. ---•-----•--•••--•.............••-._._._....----•--•-•-------•----------•••---------._...._....-----.... 0 Description of Soil------mil_A0!/ ..... ------`"-.-�xt.A........ 'kvE x ......................................................................................................................................................................................................... w UNature of Repairs or Alterations—Answer when applicable_______________________________________________________________________________________________ --------•-------------------•---•------------------------------------•-_._.._._---•-----------------••--._...-•-••-••---•••••----•-•-•--•-•-•-•---•----••---•---••----•--••--••-••-••-•--------...----•• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with f-iT r14•� the provisions of 1 i:LI: 5 of the State Sanitary Code—The undersigned further agrees not to plaVthheystemoperation until a Certificate of Compliance has been issu y the board o It Signed --- ---------- Application Approved BY �1 g Date Application Disapproved for the following reasons-------------•-------------------•-----------•----------•-------------.......................................... -•-------------------•--•----•--------------•------••-----------..-_.....------------•-----------...._..----•-•-----•--•--------------------------------------------------------------------------..._.. gg.. Date Permit No...........11-_�-�•-�-�-�-------------- Issued_....................................................... DsLe N Fins.....;7 ...... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........../_ -----------------OF............ ------------------------------------------ ApplirFation for Disposal Works Tvtw rnrtiun Urrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ................_................................................................................ _......--•-------•--•--•...--------•-•-••----•---......-------•--•--------•--------._...---------- Location-Address or Lot No. ---- Owner ¢ � Address f f A W ...................... ! ._1_...., ..........�...:.. ..±.............7-:................ ............•..............-_. Installer Address S feet l� Type of Building �,. Size Lot___________________________ q. ; U Dwelling—No. of Bedrooms...I-N ....r-.----- -• Expansion Attic ( ) Garbage Grinder ( ) --------•-- aOther—Type of Building ............................ No. of persons............................ Showers ( ) - Cafeteria 0.1 Other fixtures ------------------------- -------------------- - .............. ---•---------------- W Design Flow............................................gallons per person per day. Total daily flow...................................................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter._._-__-_-__--_- Depth................ x Disposal Trench—No. .................... Width... Total Length..........__._...._ Total leaching area....................sq. ft. Seepage Pit No------�............. Diameter......(o........... Depth below inlet..._____..._ Total leaching rea.'S.5 .......sq. ft Z Other Distribution box ( Dosing tank ( ) 0 SAA C1 �� l- F_ A G N IpT W 1 i hl S-T0 1� Percolation Test Results Performed ....... _°«°_ ....... Test Pit No. 1 4.1.____minutes er inch Depth of Test Pit .......__.. Depth to ground water_._N O __ P P � P �' - N------.--- fzt Test Pit No. 2 L.A,----_minutes per inch Depth of Test Pit----tk/........ Depth to ground water._ ------------------------------- ...................................._ ... . -----------••........----•------------ p� n - O Description of Soil �"•-�'-�•hl t f !U 1 M .i4 f� �.� N- nll y l.:!.-----•-•--••--------•--- X rJ ----------------------------------- •----------------------------------------------------------------------------------- -------- •---------------------------------- •-•-••------------•-------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ----------------------------•-------------------------------------------------------..........----•---•-•------•----------•------•----•••---------•-----•-•--------•••--------------------•--•----••---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with T the provisions of TITLE of the State Sanitary Code he undersl rt Tr1'^ er agrees not to place the system in operation until a Certificate of Compliance has been issu&VDy9the boa>�of It % Signed...................• -- •. ------------•--•-•---...--------.•_.................. -- /�� Date Application Approved By..._��773_____ 'V' V`-`4�J-c.�..c. . Application Disapproved for the following reasons---------------------------------------------------------------•---------------......--------------.............. .....................•--•-•-------------------------------------------.--------------.......--------------••---••-•-......-•---•-•--------•----••----•--------•-----•---•----•-----------•----...------ Date Permit No...........f1•- -----�r 6 Issued------------------ -----------------............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF.............. ................................ Trrtifiratr of Tnutpliattr.>e THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( 34 or Repaired ( ) w Installei at.............A----------------------'� u� ..� r .Y c....,.c� �.e::---y----- •rem ------�;;�,�---•-_--------•------- has been inst ffi m accordance with the prov sions o ITi1 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No------- _ __ ._ ._5...__. dated_---------------------..................•..... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE........................ ': ..' .......................... Inspector......... ,.. .. .................................................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH/� OF.................�llC� .ti•Y p. �#t'fit.............................. FEE.. b. -- , ...----- DispnsFai Works Tonstrurtion Wrmit Permission is hereby granted A, w, .� � —------ -1, f ... = = `-"...... {"r-+I.s mad to Construct ( ) or Repair ( ) an In$'wldual ewage Disposal System " at No............ --------------• - -�- .- ------------- T--��—cV G —^.....-1 c,/ ..-_.•(�� t CSC. - Q--S-e&et( / /as shown on the application for Disposal Works Couction Permit N F_,!=� Dated.._.._._.. ... ._ .4�;�'-._-_ Board of Health DATE----- ----------------•---- FORM 1255 HOBBS & WARREN. INC:;.yPUBLISHERS ` TOWN OF BARNSTABLE LOCATION �D MUD67AC SEWAGE # VILLAGE CaTU I I ?ASSESSOR'S MAP LOT 63 INSTALLER'S NAME & PHONE NO. 6Ea A6c t/IPRfN2 /33t-2 I SEPTIC TANK CAPACITY IU U 6 AL LEACHING FACILITY:(t-pe) Pl r (size) '/GO(� NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER ������ BUILDER OR OWNER C(-&IIY6 TO /ti DATE PERMIT ISSUED- DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No C� L ' 33 le- " TOWN OF BARNSTABLE LOCATION 26 7 SEWAGE# VII.LAGE "� ASSESS 'S MAP&LOT 0 �3 NAME&PHONE NOS SEPTIC TANK CAPACITY 16OO QY J LEACHING FACILITY: (type) �/'� C// (size) . NO.OF BEDROOMS \,3 / BUELDER PERMITDATE: COMPLIANCE DATE: Separation.Distance Between the: Maximum Adjusted 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) Feet Edge of Wetland and Leaching FacilityA any wetlands exist within 300 of lea g facili l /� Feet Furnished by�g f��17 �I�S'�Y C/,,CV7. iCIC. �� ��� � ,� i� �� ��, � 3s' o �� � -- �� , TOWN OF BA.RNSTABLE 1-6EA_r1oN �® 1 � lc��� SEWAGE # : _,VU_LAGE l.bT0�T— ASSESSOR'S. MAP & LOT O-O.3 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY SuY LF-ACH24G FACILITY: (type) l� (size) NO.OF BEDROOMS B UII.DER OR OWNERcc��W$, PERMITDATE: -7 COMPLIANCE-DATE: Separation Distance Between ttie: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility _ Fc Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Kd F'- Furnished by � � 3 �Z-sue ti . TO� ST OF B LE I:`(CATION O 1( �M CPS SEWAGE # VILLAGE + ASSESSOR'S MAP & T &PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by Ae ,9/ a.� S0, �� ;9 V [ No .:..... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF H ,AjL�TH �.. ..n...............OF..... ....L l�[1... Appliratiou for Disposal Iforks Tonstrnr#inn Frrmit Application is hereby made for a Permit to Construct ( `�or Repair ( ) an Individual Sewage Disposal --ystem at: 7 _.. - ��Ow�ner t •-- ........................................... dress orNo��a. ........................................ .......__._•_-•••-------.--.---.--......•-_-Address• --•---•-----.----. ------------------ ................................ Installer Address (� UType of Building Size Lot_�_L.bb.....Sq. feet Dwelling—No. of Bedrooms............Z.............................Expansion Attic ( ) Garbage Grinder,( ) `4 Other—T e of Building No. of persons._...._---------- ------ Showers ( ) — Cafeteria 04 04 Other fixpres -----------------------------------------------------.------•••--•----------•-----------------------------....-•---•...••........-----•......--.----- w Design Flow.............. ...........................gallons per person er day. Total doily flow..........ZZ0......................gallons. WSeptic Tank—Liquid'capacityll.QO.O.gallons Lengthg.%�."..._.. Width..q..A., Diameter................ Depth. �_ x Disposal Trench—No. .................... Width.._............... Total Length..... __..i�... Total leaching area........``.�_..c�.--....sq. ft. Seepage Pit No...l---------------- Diameter.j------D ..... Depth below inlet._�J____�.___..... Total leaching area. .R.....sq. ft. z Other Distribution box (✓) Dosing tank ( ) P--(Q35 1 aPercolation Test Results Performed by .EA46.,ycC k. �°t � ate � ,��� a Test Pit No. 1......2......minutes per inch Depth of Test Pit--4_ __________ Depth to ground water...._.._. ._...._...__. (Z4 Test Pit No. 2------Z.....minutes per inch Depth of Test Pit._)- . Depth to ground water____- .....____ R-4 • --------------------------•----.--------------------.......---------- . 1 r ! 6 -. -�...._ Description of Soil tA4 .�-'.. ..... ..�S Sb . ...-•--• -��2-----Q..-----7_----- -, •.54 b.5_.._.. xi ckl: !............................. w -----------------------------------•••------------- UNature of Repairs or Alterations—Answer when applicable............................................................................................... -------------------------•-----•••------------------------•------------•--....------....----......•-----•--------------------------...-- .............................................................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLi: 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 e bo rd of health. .. .. . ................... ---- .......-----------7-- Application Approved BY ' = _ -----••-••--........ ........-- !_.................. Date Application Disapproved for the following reasons---------------••---•--............................---------_......=----......................................... --.....-----•-•------•-------•---...---•-•---------••----------•-•---•-•-------------------•------...-------•-•................_..----•---------------------------------...----•--------•-••-------••--- Date PermitNo......... ....`.r ---_. Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HfEALTH C 1. ...... ...... ......OF.....�a�l.t 5 ( b • .......................................... Appliratinn for Disposal Marks Tonstrutdion Famit Application is hereby made for a Permit to Construct ( `�) or Repair ( ) an Individual Sewage Disposal {System at• o °L'lotion- ddress or Lot No. ..... ........................................................ ............................................. ----- .... .----•----------.................. ..... Address /. (...... ...................... Installer Address UType of Building 2 Size Lot.._......!47 U......Sq. feet Dwelling—No. of Bedrooms............................................Expansion�11 Attic ( ) Garbage Grinder ( ) 'k Other—T e of Building . No. of persons........4................. Showers — Cafeteria P1 Other fixtures .---•------••••-••••-•-••••-•--•---••--.......••--••••.-•---•-------••----••---------------.......................................................... Design Flow............................................gallons per persons pergday. Total Oil flow..........4zd......................gallons. WSeptic Tank—Liquid capacit)42!2v.gallons Length�--LP....... Width..... �1_ Diameter................ Depthn... ..... x Disposal Trench No..................... Wia��D�.............. Total Length.._�J....�_._... Total leaching area... _ sq. ft. Seepage Pit No_____________________ Diameter.---._-......__..... Depth below inlet_....._............. Total leaching areaZ7.. ......sq. ft. Z Other Distribution box (Y-1") Dosing tank ( ) 1 '-' Percolation Test Result Performed b(Af F �-;An t t/U>✓�,1ta�C_. 't.. �<Date.3. ,�. �_____________________. Test Pit No. I......�._.._minutes per inch Depth of Test Pit.13................ Depth to ground water........................ rs, Test Pit No. 2......4'......minutes per inch Depth of Test Pit... ............ Depth to ground water..... .......... a Descri tion of Soil?.( ­(''­ n ._..._....0__...._ �.-5 v h Ot w -••....................•-••••---.......-••-••..... --•�`n ai orr�_Sc��d--------------.....---------.Z-.-.-15----- LI�._un,_.. c n I x ------•--•-•---------------------••••----•------•---------------------------•---•-•-•-•-••••...._..----••--•-••-•••-----•••••-----•---•-----••---•-•-•--•-••-.._..-•---••--..................•-•----•-•- U Nature of Repairs or Alterations—Answer when applicable............................................................................................... 1 Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIME 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 b he b and of health. - _ ----- -- --•- .... _ 6 Application Approved BY••••--•-•••.... ..........••••••--.................�—.�: y ----`=........... Date Application Disapproved for the following reasons:---------•--•----------------------------------------------------------------------------------••-----••-....._ ---------------------------------------------------•--------......------------------...........------•---•••-•-••--••---•-----•••-•-••••-•-•-•••------•---•---•-•••-•••••---•••--------.........._...--- PermitNo......................................................... Issued................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF... HEALTH ..........................................OF.................................................................................... Trrfifiratr of Toutplianrr TK6�h0 GEZ.T-Z�Fhat the Individual Sewage Disposal System constructed ( ) or Repaired ( ) bY--------------------------------c��--►-'-------•--------••-------------•--------•---------•------------- ------------------------•••-------------------------------•--------•-----------•--•------------ f 0•T 5 � 17 U 01-: Install at N it- at ...............•-----•--••--••-••-. has been installed in accordance with the provisions of TI of T tate Sanitary Cc�tle a described in the application for Disposal Works Construction Permit No...�� .'_� ..... dated__ T/..�.?._ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FU CTION SATISFACTORY: J, DATE................ . ---• �' ...... Inspector.... . --- .......... ...........................-----.......... THE COMMONWEALTH OF MASSACHUSETTS _, ----'BOARD OF HEALTH I o � ..................`.........................O F................:.:... .......................................................... No....................i. Disposal nrk's ��rnitration arms Permission is hereby granted...........J.d A.N LTV r ........... ...........--•--- .... .. to Construct ) R air (� ) an Individual Sew) a Disposal System � 5�__. P �'7C Cr r-7A.. C ��l •--•••................ /J /t 2. Street as shown on the application for Disposal Works Construction Perm- _� .._. Dated......Z�...._ .. ... ............................................. DATE........... ••-••••--••-•-•••-•-•••----------------- Board of Health FORM 1255 HOBBS & WARREN, INC., PUBLISHERS y # ASSESSO�RQS MAP NO. 03q PARCEL L O C A T ION SEWAGE PERMIT NO. //r,8s e� 1Q,we VILLAGE 41 4,N S T, AALER'S` NAME i ADDRESS �-BU I-LD E R OR OWNER Jim k�T / L fR DATE PERMIT ISSUED DATE CO.M.PLlANCE ISSUED 4 Val i `YS TEM PPOFI. L E NOT TO SCALE TOP FDN. FINISH GRADE -y9 �' FINISH GRADE OVER EL . FINISH GRADE OVER � - :.o... DIST. BOX FINISH GRADE OVER SEPTIC TANK wp• a LEACHING PIT VARIES \ 6 •�' �'O.°oo.'e:i'�,A',d•O.G:e.'•d.; e: • :D:.�,• e,. :,. .d.. , .•d•,• ,d• •• — 0 .• o. o..o. io.. .°:e:.,•'.:o _.•e;o :dro:o'.°� 3u OF 1/Bii 1/2u 12" MAX PRECA S T CONC. OR 3 ASHED PEA S TONE BRICK 6 MORTAR OUTLET PIPE LEVEL TO 12" BELOW GRADE o b:4.•'0 FOP 2 FT T. MIN. : •0 •a •o' �Q •d. C. I. OR PVC TEES y.S" ,,. - � V�',o. •' D;Q•.. :D •od�0:� 40 BSMT. FLP. o0 0 . a 4 O 0 0 GALLON O �.: DISTRIBUTION Old' a� PREC S T CONCRETE rNs rAL L ON LEVEL BASE 3/4„ ro s—s/2 PRS'CA 'T :'a::°".•°.,o. o:'°: b WA SHED o. H— O REI cRUsD • FORCED I 4 f o CONCRETE :I a; 0.0.0; :m.ao.o,..d:d:::o :o o'.o o;o. p'.:�..a g'•'d::.::.' '::d. 'o.' o:o.'o: STO/1' a .b;;O.•0, D..d.p�.0:0•A•.D.'O.O:.•b:•o•;0,. O;•b:O• D•;O'4.• :b. . 0;.,O•b:D. : p,, 'Q ,Of ,O:'• H-- 0 PE.INF. SEPTIC TANK °.'b.0: INSTALL ON LEVEL BASE NOTE.' E.YCA VA TE TO EL EV V. - 7, ''`OR .b,a, o D a .a• a LOWER TO REMOVE ILL IMPERVIOUS MA TERIA L BENE'A TH THE L EA CHING A,L?EA , REPLACE EXCA VA TED MA TERIA L WITH CLEAN, CLAY FREE SAND lo Lp EFFECTI VE DIAMETER 3-0 LEACH I , .ING PIT � � y8 z � ,� GENE- NOTES J ?. ALL ELEVA TIONS SHOWN ARE BASED ON A .s"5U/l4,E 17 INS TALL ON LEVEL BASE I PRECAST CONCRETE 2. ALL PIPES IN THE SYSTEM MUST BE CAST IRON LEACHING PIT O..R _SCHNEDULE 40 PVC. I" +r �• a O -� T. ON Pl T 3. THE BOARD OF HEAL TH MUST' BE hL T IF IEC •� °`- ' _ r.._. \ J/ WHEN CONSTRUCTION IS COMPLETE PRIOR -�w ?COL A TION RA TE• TO BA CKFIL L ING 4. ANY CHANGES IN THIS PLAN MUST BE APPROVED MIN•/IN. y1000 GALLON d� BY THE BOARD OF HEALTH AND CAPE & ISLANDS WITNESSED BY.• ` PRECAST CONCRETE 0"/ SEPTIC TANK 0 SURVEYING CO., INC. .� � �rJ- 5. MATERIALS AND INSTALLATION SHALL BE IN yG ' " ��'� COMPLIANCE WITH THE S TA TE SANI TAR Y `' BRD. OF HEALTH DESIGN DA TA � CODE - TITLE V AND LOCAL APPL ICABL E DA TE.• I RULES AND REGULATIONS /.c ^ Lo "�, ,, 6. NORTH ARROW IS FROM RECORD PLANS AND Top,o.M �9 i NUMBER OF BEDROOMS r� . '�' a f'w// a w.'►' N 4 . rr J u d�a,� S b:«, IS NOT TO BE USED FOR SOLAR PURPOSES GA RBA GE DISPOSAL �a zoo 4,a, 7. FLOOD HAZARD ZONE c° z DA IL Y FLOW 2 2 c> GAL . v o B. WA TER SUPPL Y SEP TIC TA NK REO 'D. <=� GAL . h /o c� c SEPTIC TANK PROVIDED GAL . LEACHING REOUIRED GPD. c SIDEWALL AREA = /` �" S. F. S. F. X 2---s- G/S. F. - J "GPD BOTTOM AREA S. F. Ie ' LEGEND //—? S. F. X A a G/S. F. GPD LEACHING PROVIDED = GPD ----- - — -w - .. fl u ff'•c r No W t-�c p PROPOSED EL E VA TION ✓r i ---moo -- EXISTING CONTOUR SINGLE FAMILY RESIDENCE &' OBSER VA TION PIT a: P R U Q EN C E L A N E ❑ DISTRIBUTION BOX �9��. JAMES° ��,`, PROPOSED SEWAGE DIvS'POSA L SYSTEM Q LEACHING PIT a 29 ID 94 PREPARED FOP RHO 4� oFFSSIOPoAL4 ® o SEPTIC TANK �y � - LJA MES S TEIDL ER LOT 85 PRUDENCE LANE tRP I RESERVE ^� Dw; CO TUI T -- BA RNS TA BL E MASS. ; PIPE INVERT ELEVA TION CirLE �9 �r r�o PLOT PLAN CAPE c� ISLANDS SURVEYING, INC. . c�sT� , SCALE: ? `ss� ,�"CA L E AS NOTED P. O. BOX 334 2 c�� .5:.� • = 3 p — .� �t��� . RAP SEC PC d LOT HSE ��`A�°d �'�3. s � �r��'7 Tt�A T T C,k"s�T, IAA�'S �o —T E_ST Hc�:)LE L� -rnP-�oLJrJPA-flotJ V4TE : C *,f8s IJO. p 7oa5 Cd ELEV. 57-0 BY : E \lF ES rlGit111? 10G ASSOCIAT : O LOUGH LW In1C.. B�?AQP of H EALTt-I : J. T71�r�tJ I tJG I z"M�nl. Z`/® M I f�. SLOPE. c.�v STz l�aC� ��T # � 4 SCFIED 40 PVC PIPE — 1 Z 4 SCHED 40 P-JC PIPE d qb 7SC+�D4dWC• PIS 55-7 O 55.7- 0 _ 0- I/8' : 1 P410-.SI�PE _ OOTE F. t/e r i Mitt. sioPE �—r- Z LA �� AS n LRAM �. LCAH SL 15 - 5. �— Y T � _-5IJ IL 5A7 12' \5.4.7 537 Z4 54.45 4 O F54 !7L 53-9a I_I Q 01 53.'7 I GL70 GALLOf,I <. 4- Z CLEAt-1 CLEAtJ -0 STOIJ E ALL ��Q p 3 C%1T P CAST PA ST M>=t�1tJM MEDIUM PIS-TRIt3U-I'10� Box L£AG0 :r I� GAL-PRE-CAST -Z r-Ilo SAND SAP. Tk Prr SEPTIC A� - --i { .4 7. w,J IG2Avfl �l{6fAVEL I SEWAGE S`(ST�M DETAIL � i�RC�(=ILA SC ALF = I/4 = 1 0 43.7 144" - 43.7 l44� IJ o t�lAT�2 i=►JcotJrJ�EI� FRUPE1JCE LAtJ v I - . 11.5.G� 5z .2 �2-Co 3.3 DESIGN .._DATA I \ / <Percolation Rate: E M11J IdCH Garba e`Dis osal tCD / 9 P I I ' Design Plow: 3 bedrooms x II o gal.s/day/bdrm = 3 3o gals/day 0 Septic Tank: 33CD gals/day x 150 % = 49F5 gals/day Use: <I) 1000 G ALL(DQ PREr—A57- SEPTIC TAt J K. I { Distribution $Dx: 3 0L1TLf-:T PRECAST PIST- BOX 53.4 5g s ( 5I3,8 B) leaching Facility: (1) 1000 .GALLOIJ LE.AC_0 PIT (PRECAST H - 10) 35 t 55,4 cr3 SidewB11 Area: iSaso ..s.f- x a.5 9 y := 4-7I-as gals/day . al5/sf_/da N Za' Bottom Area: -,s.�4 S_f_ x 1 .0 gais�'s.f./day = �s.sg ga3s/day t4' 1 I ":Total = 549. 79 gals/day ul 1 1 OD Q P�vFtpSE� �� { fNAL"• �1DTS _ N Q j CIJEL7 1�1G ( 1- Sewer pipe minimum 4" dia_ Schedule-4D:RVC _.nr°equal @ 1/8":i', slope- p 1 q 114'1:1 ' slope before septic tank: 310 .:CM12 15.04 (5) ,' 3 5�ia 2- All stone must be washed and free from- iron, fines, _and dust in place- _ The minimum depth of cover material stone 'shall be 12 inches_ 'p- 1 19 ( 310 CMR 15-11 (7,11) zip S i Q 3- The grade above and adjacent tD the` leaching `facility shall slope at least 2% to prevent accumulation of. surface -water._ N 57 { -4- Topsoil, peat, and-other impervious materials shall be removed from J _ 0 5o 7 I all areas beneath the leaching facility_and -for :a distance of 25' in z G I v all directions therefrom when the 'leaching facility is above natural ground; 10' when below natural'ground.. 31 D CMR 15:�2 (17) { 77 3- The distribution box outlet pipe shall be level-for 2 feet. WATER C { I f- Manhole covers for septic tanks shall not be more than 12" below --- finished grade_ 310 CMR 15_D5 '(12) Lc�T - 57- Q 55.3 z.Z gOCo.Coo 1'- 5 -3 A. PAUL , SWARD c c I C' 519.5 I � 10 gE►JCN MAk'K 57 .S I EL. Go .00 ON HYP. 'TAG 5�L7 c i No. Z14 Lo P4 >T F0P ( , G-1t4aRN ii AA Square;•1543 Rwte :28 ' '1 i Massachusetts .-fl2632 existing elevation front yard setback = 30 ���fl���-� �ntervi e s I FLA . Dsed elevation side - 15 T its 8) 29D-2B82 — — existing elevation -rear = 15 siting and design engineers --civil and strxtural proposed elevation flmd zone G = teSl;'401e -water supply Tp1A11.1 roL �Na E5 REVISIONS /� IExCEP!ASWMTDI NO. DATE ell SITE S E�AG e- FL A,� utility pale Than reference LCP 22824 -SO-3 DEC+*1A1- I WELLIt467FOQ ICELLEY fire=hydrant 2oninp district R F Lc>7 &3 e s COR Prz,Jv54- -/pA IE},ICE LdS * Z CcrflllT COh�1{ DF.I S , Co"?l�iT M5 • — = water,service A55ESSOR.S MAP 406 L. I 81 fWAC"ONAL As 3 DRAWN BY SCALE P.J.D f�IoTE17 Jol3 88- 143 * LYiK'D .DATE I DRAWING NO. ANGULAR TRACED APP'D A,- -