HomeMy WebLinkAbout0066 BLANID ROAD - Health 66 BLANID ROAD
Osterville
_ A = 140 — 063
Q
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
66 Blanid Rd.
Property Address
Glen Scandlen
Owner Oviner's Name
information is
required for every 0 terVille MA 02655 4-2-13
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
filling
outimportant:when A. General Information
filling out forms `��pttunllfrgp
on the computer, TH OF 1�1AS v�,�i
use only the tab 1. Inspector �� �•.
key to move your y
cursor-do not James D.Sears 1 `��• .DAMES m
use the return 50• J -s_, j
key.
Name of Inspector :v:
CapewideEnterprises,LLC
�i Ise I 1 Company NameR.
153 Commercial St. %,,�rrsr IN SV��"O
Company Address
Mashpee MA 02649
Citylrown State Zip Code
508-477-8877 S1623
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
1 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
4-3-13
ID64c.toes 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.
L
t5ins•3113 Title 5 OVIns ' m:Subsurface Sewage Disposaf System•Page 1 cf 17
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Commonwealth of Massachusetts
-, Title .5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
66 Slanid Rd.
Property Address
Glen Scandlen
Owner information is Owner's Name
required for every Osterville MA 02655 4-2-13
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist Any failure criteria not evaluated are
indicated below.
Comments:
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):
I
Mns•3/13 Title 5 Orndal tispedion Form:Subsurface Semp Disposal System•Page 2 of 17
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y
Commonwealth of Massachusetts
U
� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
56 Blanid Rd.
Property Address
Glen Scandlen
Owner Owners Name
information is
required for every Osterville NIA 02655 4-2-13
page. City/Town Stale Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumpstalarms not operational. System will pass with Board of Health approval if
pumpstalarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5rts•3/13 nue S Ofridal 6npedbn Form:Subsurface Sewage Disposal System•Paae 3 of.7
1
Commonwealth of Massachusetts
Title 5 official Inspection Form
i= Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
66 Blanid Rd.
Property Address
Glen Scandlen
Owner Owners Name
Information is
required for every Osterville MA 02655 4-2-13
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
f� ❑ ❑ Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
Liquid depth in "
q P
is less than 6 below invert or available volume is less
than %day flow ,�fT
tslns 3113 Title 5 OWN inspection Forth:Subsurface Sewage Disposal System-Page 4 of 17
Hpr u,s i s uu:4sp p.o
Commonwealth of Massachusetts
Title 5 Official Inspection Form
"Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
-'66 Blanid Rd.
Property Address
Glen Scandlen
Owner Owner's Name
information is
required for every Osterville MA 02655 4-2-13
page. CitylTawn State Zip Code Date of Inspection
'B. Certification (cont.)
Yes No
0 ® Required pumping more than 4 times in the last year NOTdue to clogged or
obstructed pipe(s). Number of times pumped:
❑ (A 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.
❑ 1Z Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either`yes"or"no" to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone 11 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.
t+n,'3f'3 TBie 5 OKciai inspeatn Form:Subsurface Sewage D sposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
66 Blanid Rd.
Property Address
Glen Scandlen
Owner Owner's Name
information is required for every Osterville MA 02655 4-2-13
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
❑ M Pumping information was provided by the owner, occupant, or Board of Health
Q 0 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?
El ED Have large volumes of water been introduced to the system recently or as part of
this inspection?
® Q Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® Q Was the facility or dwelling inspected for signs of sewage backup?
® Q Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® Q Were the mduilm uncovered, opened, and the interior
inspected for the condition of the IMMMMMtees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ N 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 Absofrption System (SAS)on the site has
been determined based on:
® Q Existing information. For example,a plan at the Board of Health.
❑ Z 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): NA Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
lSins-3/13 Title 5 Official lnspecilon Form:Subsrrface Sewage❑Ieposal Sys;em•Page 6 of 1T
Apr us 1,5 uu:4sp P.i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
a
66 Blanid Rd.
Property Address
Glen Scandlen
Owner Owner's Name
information is required for every Osterville MA 02655 4-2-13
page. Cityrrown State Zip Code Date of Inspection
'D System Information
Description:
The system is a cesspool and pit.
Number of current residents:
0
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
2011-9,00OGal's
Water meter readings, if available(last 2 years usage (gpd)): 2012-10,000GaI's
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: NADate
Commercial1industrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seatstpersonslsq.ft, etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? El Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5km•3113 Title 5 omclal Inspection Form:subsurface sewage Disposal system-Page 7 GP 17
Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
66 Blanid Rd.
Property Address
Glen Scandlen
Owner Owner's Name
Information is
required for every Osterville MA 02655 4-2-13
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: NA
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: 500
gallons
How was quantity pumped determined?
Reason for pumping: after inspection
part of inspection
Type of System:
® soil absorption system
® Macesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system(yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Altemabve 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 IIA system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
t5hs-3113 Title 5 Offlclal Ins ection Form:Suhsurtace Se
wage ewgge Disposal System•Page a of 17
Apr w 16 u6:44p p.y
Commonwealth of!Massachusetts
MoRzimf
Title 5 Official Inspection Form
Subsurface'Sewage Disposal System Form-Not for Voluntary Assessments
kvi- 66 Blanid Rd.
Property Address
Glen Scandlen
Owner Owner's Name
information is required for every Osterville MA 02655 4-2-13
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
main pool na new pit installed 1986 permit#86-602
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 22"fef
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.):
Pipeing cast iron from house. 4" PVC SCH 40 pool to pit.
Septic Tank (locate on site plan):
Depth below grade: 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:
Sludge depth:
t_lns 3113 Title 5 otrelel tnspectlon Form:Subsurface Sewage olsposal System-Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
' 66 Blanid Rd.
Property Address
Glen Scandlen
Owner Owner's Name
information is
required for every Osterville MA 02665 4-2-13
page. Cityfrown 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
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined?
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
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: v- - Date
ts'vis•3/13 Thle 5 O'Lcial Inspedon Forte Subsurface Sewage Disposal System-Paga lO of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
66 Blanid Rd.
Property Address
Glen Scandlen
Owner Owner's Name
information is
required for every' Ostetvllle MA 02656 4-2-13
page. Cityrrown 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 pet 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-3113 Titles Olrwial Impeaicn Form:subsLeaue sewage Dlsposw system•Page 110117
tkpr uo i o VO:40p P.i c
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
66 Blanid Rd.
Property Address
Glen.Scandlen
Owner Owner's Name
information is .
required for every Osteiyille MA 02665 4 2-13
page. Cltyfrown 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
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:
Mns•3113 Time 5 Official Inspection.Form Stbsurface Sewage Disposai system•Page 12 of 17
Hprus 1;s UdAbp p.-1,5
Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
66 Blanid Rd.
i-
PropertyAddress
Glen Scandlen
Owner Owner's Name
information is
required for every -sterville MA 02655 4-2-13
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
.® leaching pits number: 1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions: —
❑ overflow cesspool number.
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leaching is a 1000 gal . H-20 pit w/stone. Pit at 55" below grade w/cover at 16"H 20 cover.
Pit in shell driveway 29",water in pit. No sign of over loading or solid carry over. No high stain
line.
A*j Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration 1
/Depth—top of liquid to inlet invert 12"
Depth of solids layer 411
Depth of scum layer
1"
Dimensions of cesspool 6' Deep
Materials of construction Block
Indication of groundwater inflow ❑ Yes 0 No
tShs.3113 Title 5 Official hspection Form Subsurface Sewage Disposal System•Page 13 of 17
i
nF, vv i. vv.-rvN N.i•7
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
66 Blanid Rd.
Property Address
Glen Scandlen
Owner Owner's Name
information is
required for every Osterville MA 02655 4-2-13
page. City/Town State Zip Code Date of Inspection
D. system Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,
etc.):
Main pool and cover at 14"below grade pool at working level. No inlet tee. Outlet 4"PVC w/tee.
No sign of over loading pool to be pumped after inspection
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.):
tSns•3/1 a T111e 5 Mal Inspection Forrtr Subsurface Sewage Disposal Sysieli Page 14 of 17
Apr u3 13 uo:4up P.t a
Commonwealth of Massachusetts
_- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
66 Blanid Rd.
Property Address
Glen Scandlen
Owner Owner's Name
information is
required for every Osterville MA 02655 4-2-13
page. Clityfrown 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
13 � = 1 /
I
I
i
t5ins•3113 7n0e 5 Offidal Inspection.Fonn:SubsW.ace Sewage DIsposel System-Page 15 of 17
L ,
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
66 Blanid Rd. l
Property Address
Glen Scandlen
Owner Owner's Name
information is
required For every Osterville MA 02655 4-2-13
page. Cltyrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells ENO
Estimated depth tq(high ground water: 10
feet
Please indicate all methods used to determine the.high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: -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:
T.H. off abbutting property#58. T.H. date 8-29-12 No G W at 10'
Before filing this Inspection Report,please see Report Completeness Checklist on next page.
rsns-ins 71t1e 5 Official Inspection Form:Subsurface Sewage Disposal System-Page la of 17
Apr u:S l;S ut5:4up P. l l
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
66 Blanid Rd.
Property Address
Glen Scandlen
Owner Owner's Name
information is
required for every Ost:erville MA 02655 4-2-13
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D(System Failure Criteria Applicable to All Systems) completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5im-3113 TIUe 5 otndai mpeaion Form:Subsurface Sewage Disposal Syslern-Page 17 of 17
J
ASSESSOR'S MAP NO. J d PARCEL ®� y�
LOCAT N n SEWAGE PERIMIIT NO.
_ / �( ��-
VILLAGE
oG3
INSTA ULER'.S NA E i AAPRESS
J P
8 U I L D E R OR -OWNER
DATE PERMIT ISSUED ..,.,� Z/1 Z&
DATE COMPLIANCE ISSUED
1
r a
t /0 t
.x
C 4�P ✓ c
Wa 4f-- (10
Fing.1
THE COMMONWEALTH OF MASSACHUSETTS
BOARD!19F, HE T
0 F..... .............................
Appliratiou for Bhopogal Works Tonotrurtion ramit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at:
........................................................................................
Location-Address or Lot No.
--------------------------------------------- - ---------------------------------------------
wner Address
L................................. .................................................................................................
Installe Address
Pype of Building Size Lot............................Sq. feet
U
4 Dwelling�No. of Bedrooms............................................Expansion Attic Garbage Grinder ( )
Other—Type of Building ............................ No. of persons............................ Showers Cafeteria ( )
Otherfixtures ------------------------------------------------------------------------------------------------------------------------------------------------------
Design Flow............................................gallons per person per day. Total daily flow...........................................-gallons.
94 Septic Tank—Liquid capacity......:.....gallons Length................ Width___.._...._..... Diameter......_.._._.... Depth...._.._........
Disposal Trench—No. .................... Width.....___.....__._... Total Length._.................. Total leaching area....................sq. f t.
Seepage Pit No--------------------- Diameter.............._..... Depth below inlet.................... Total leaching area..................sq. f t.
Z Other Distribution box Dosing tank
Percolation Test Results Performed by.......................................................................... Date........................................
aTest Pit No. I................minutes per inch Depth of Test Pit.................._. Depth to ground water..__..............._._..
Test Pit No. 2................minutes per inch Depth of Test Pit..._..........._._.. Depth to ground water........._.........._...
04 /- ------------- .... .....................................................................
........................ ......................................................
... ..........
0 --- ---�4—
Description of Soil.. _"(1
---------------*-------*...............*------------------------ ...... -------------*-----------------------------------"----------------------------------*------- ---------
.............................................................................................................. AJ.......... ...............
Nature of Repairs or Alterations—Answer when applicable------ ------
U ..................
.......................................................................................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TH'I a 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has be issued by t bo o lth.
Signe ... ... r.
.. .. . ....
to r
Application Approved By........................................................... ...........
Da
Application Disapproved for the following reasons:......................................................................................... ..................
......................................................................................................................................................................... ...............................
Date
PermitNo......................................................... Issued-.......................................................
Date
Ficim
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HE�L
,/ �' .......... .... i.�. ,.�, .aP� -�'-. ............................................
A 1pfiratiun for Dtspuutt1 Works Tanstrurtion rrrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at 1
.......°:.Sr_.... t «,.�jt °..X ••»f --�'.G ............:........�J!.t:..:✓�f9r. /1:................................... .........................................
Location-Address or Lot No.
�...�'... ............... ............................... . ................ ............................................................................
z�`•�.7Owner r'r Address
Install, Address
Type of Building ty Size Lot............................Sq. feet
Dwelling`—"~No. of Bedrooms.......................:....................Expansion Attic ( ) Garbage Grinder ( )
04 Other—T e of Building No. of persons............................ Showers — Cafeteria
Other fixtures ......................................................
Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
Septic Tank—Liquid capacity....:.......gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area...................sq. ft.
3 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. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.........................
1-4
Test Pit No. 2................minutes per inch Depth. of Test Pit.................... Depth to ground water........................
x '' .........................................................................................
d� --- -- ' , ....
f
0 Description of Soil........,� . `z, k °... .: �.. ��. ! �
V ......................
...•------....--•------------..... ----------
------- ---.-- --- .....--•-------------------.---------------
W ---------•••------•------------•---------•-------------------•-•••-•-•••••---•-••••...-----........--------•----•-----•-••••-•••-�....-- :.F .....
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 TITIS 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 We board of health. ,r
f/ f r,rr r _
Signer]......�'. �� . :,... ✓'I t`� �����'�.': "'�. ! '� f '+ ...
Application Approved By.......................................................... , --------•• -----------�O tD e 26..•--
Applieation Disapproved for the following reasons-------------- -------------------------------•-•---•--•------------.....-•----------...... ............... .
---------------------------------------------------------------------------------•----.......-•-----•--..............................------•-------................................ ..-----.....
Date _
PermitNo......................................................... Issued.......................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF.
j Tatif iratr of Tomplittiu9
P
TT S I "I, ERTIFY, That/the Individual Sewage Disposal System co structed ( ) or Repaired
Y•- • A f ......................................................._
J���..•'s _ �/ P l Installer 41140
at...........:":y` h''y ...........;re.•� tF.:G'c"�%C.y:: ...... .° ..1 F 5:::.... ...... �1................_......................................_..
has been instilled in accordance with the provisions of TITLE 5 of The State Sanitary Code as des ibed in the
application for Disposal Works Construction Permit No........... dated_._........0" .Q ...............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUAR NTEE THAT THE
SYSTEM WILL FUNCTI N ATIS A ORY.
DATE.................. f -•---•... Inspector........ ..........................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
No....9�?-..�?..� o�............................................OF.....................:....... .................................................... F>t ..... ...............
' i��ru�tt1Works Tunstrurtiun f rrmit
Permission is hereby gtanted........:.::............
to Construct ( ) or Repair (. ) an Individual Sewage Disposal System
atNo......: ---- .........---•.............•-----•-•-•---••--••-•--•....:� .�...........................-----..................... .. .............
;'. Street q&- 6oZ.-
as shown on the application for Disposal Works Construction Permit No.......... ......... Dated...........
Y. ................................... ...'ed- .....--.............................
oard of Health
DATE.................�+..� ..... .................................
FORM 1255 A. M. S LKIN. NC.. BOSTON
ASSESSOR'S MAP NO. J PARCEL Q�
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VILLAGE
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B U I L D E R OR OWNER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
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$ h m Z 66 BLANID
OSTERV I LLE,rt I'1A 02655 , BARNS'TLE HARE®REUILDER,S, ,
PO BOX 483 BARNSTABLEE .02630
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ELEVATION PHONE: 774-521 3899 i
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BARNSTABLE HARBOR, BUILDERS
j OSTERVILLE, MA 02655
_ PO BOX 483 BARNSTABLE, ILIA 02630
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m z •• 66 ELAN I D BARNSTABLE HARBOR BUILDERS
1 oSTERVILLE, MA 02655
BOX 483 BARNSTABLE, MA 02630
N EXISTING CONDITIONS PHONE: 774-521-3899
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PO BOX 483 BARNSTABLE, MA 02630
s _EXISTING CONDITIONS -521-3899 PHONE: 774
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ADDITION
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7'-2 1/2" 12'-9" A'-II" 1J1 a7
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TOWN OF BARNSTARI E
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LOT 11
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MICHAEL G. & SUSAN M. CRASNICK, TR. j uj \
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STOCKADE FENCE O�;, li
i 00.U HUB � 99.9 S8�33_2�"W - � ---cr--- ---o---a---c --
FOUND x-a- ;, o--r_�-❑ a--- u
' 108.82' 16"
`-- OAK 16 4
i 0U.0- / SHED Q c- PROJECT
z HYDRANT 'yg 8 :�PONo LOCATION
99.9 100.1 o O m STEPS TO s.8' -_...-
L-• BLANID ROAD
BE REMOVED 99 5 99 6
/ EXISTING SHELL DRIVEWAY O>
x 99.5 LOCUS
/ 99 5 EX/ST/NG QECKS, NOT TO SCALE
BENCHMARK: 99.5 SH0#ER AND
g9.6 DECK STEPS TO BE 10 ,
NAIL & CAP CESSPOOL EL. 101.17 REMOVED CEDAR
EL. 100.00 (APPROXIMATE O
j LOCATION)
CB/DH
FOUND 100,1 t 100.0 99. PRopoCONC. PATIO PAYERSED 99.
,r 10p� PROPOSED
PAT/0 z
c NEXI STERN UNHEATED PI" LOT 4A
r`' AND < SCREEN
rn dYAZKdYAY PORCH 99.4 99.6 O t N/F
m /0 25.7' I DECK JOHN H. & LINDA C. MURPHY, JR.
99.5 SHO R w
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v / m = EXISTING WAll � 99.3
Y -��� 99..5 HOUSE #66 ;2
m F.F. 101.43 B LK CEDAR
H D LEGEND
z 99.8 PROPOSED �n
WALK WAY NV CONC. t�YALK!?�AY PINE
!?�ALKIYAY A AND o �0
EX/S g 4 99.2 .�j O __ oO___ EXISTING 10' CONTOUR
`� CONCRETE STEPS 'STEPS 98.9 x 99.5 EXISTING SPOT ELEVATION
TO BE REMOVED
9.5
O
` ��•9 CESSPOOL � LOT 10A 15„ PINE TREEE •
99.8 99.4 / 99.5 8 686 S.F. CEDAR r
O EXISTING STONE WALL
a99.8 z,�a' •
CATCH PROPOSED `o EXISTING HYDRANT
BASIN PROPOSED 1 GAR
RIM=99.84 O PAYED OR/VE t� 99.5 CB/DH
GARAGE FOUND 0 CONCRETE BOUND WITH DRILL HOLE
D CONC.
COVER
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CATCH X 99.6 �Lu
BASIN
REM=99.12 PUMP AND ` w
0
x REMOVE
099.i ABANDONED o LOT 5A
STRUCTURE � STOCKADE FENCE ! N/F
9.8 SPLIT RAIL FENC
I gg5 $8.33�2o ww yg 2 99.0 DONALD M. SULLIVAN, JR.
.
100.0 99.5 95.561 99.4 99.5 & LAURA DARWIN
99.7 99.9 SHED
LOT 9A
N/F
ESTATE OF SALLY FISH
PLOT PLAN
FOR #66 BLANID ROAD
PREPARED FOR
,I OF Mg BARNSTABLE HARBOR BUILDERS
s�yIN
GENERAL NOTES. s sL�;• �N OSTERVILLE MA
CIVIL PLAN DATE: MAY 23, 2013 PLAN SCALE: 1"=10'
1. HOUSE NUMBER: 66 " No.asasa
2. ASSESSOR'S NUMBER: MAP 140, PARCEL 063, LOT 10A `oN^, G �'� CIVIL ENGINEERING O UT WETLANDS PERMITTING
3. ZONING DISTRICT. RC
b� WASTEWATER DESIGN � � COASTAL ENGINEERING
4. FLOOD HAZARD ZONE: C (F.E.M.A. MAP 250001 0016D)
TITLE 5 PLOT PLANS .� �c PIERS AND DOCKS
5. TOPOGRAPHIC INFORMATION COMPILED FROM AN ON THE GROUND SURVEY. R1�
6. ELEVATIONS SHOWN ARE BASED ON ASSIGNED DATUM. 10 0 5 10 20 LAND USE PLANNING 11rGjE COMMERCIAL/RESIDENTIAL
sormg Cape Cad and Southeastern Massachusetts
SCALE: 1 INCH = 10 FEET 29 SIMPSON LANE UNIT 1 - FALMOUTH, MA - 02540 - 508.495.1225 - 508.495.3229 fQx
PROJECT NUMBER: 13036 CAD FILE NAME: 13036SP DRAWN BY: L.M. SHEET 1 OF 1