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HomeMy WebLinkAbout0024 JANES WAY - Health 24 Jane} ' Way isterville A = 146 047 1 C 'OWN OF BARNSTABL E r LOCATION S SEWAGE # 2Gc 710 VIi;1AGE �'` ASSESSOR'S MAP&`LOT �� -INSTALLER'S NAME&PHONE NO. p n f_ SEPTIC TANK CAPACITY 1�Uo 1\RP 114c2- fl-peg LEACHING FACILITY: (type) t ' T (size) NO. OF BEDROOMS BUILDER OR OWNER / PERMTTDATE: 1 a Il oo i COMPLIANCE DATE: ►_T /��' 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 I aching facility) Feet Furnished by �� .e-t-� oa ,AO a � a� 4 No. ;;7 Feet•✓ c.! THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: es PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZIpprication for. Miopogar *pgtem Con.5truction 3permit Application for a Permit to Construct( )Repair(i/)Upgrade( )Abandon( ) D Complete System Andividual Components Location Address or Lot No. 7�kr j Q�up �Q� Owner's Name,Address and Tel.No Assessor's a,Parcel �•' ��I✓ ""'/ ��� � 0 � Q5 7e/_L11IB Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank I(!uy b Type of S.A.S. Description of Soil Nature of Rep 'rs r Alterations(Answer when applicable) GM-61 1117 Date last inspected: Agreement: The undersigned agrees 10 ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this azd f .r:y Signed Date Application Approved bY Date �t PP PP Application Disapproved for the following reasons Permit No. 1;lWV- 0 Date Issued �. •-,� No.'+®f `ri` ; Fee 1 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: es PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS �, ✓� Z[ppYication for.Migpogar bp! temp Congtruction Permit Application for a Permit to Construct( )Repair(V)Upgrade( )Abandon( ) ❑Complete System [E dividual Components Location Address or Lot No. p Owner's Name,Address and Tel.No. Assessor's a cep Derl�,/�/� Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) ' Other Fixtures 'r Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title o Size of Septic Tank Type of S.A.S. Description of Soil i Nature of Rep�''rs r Alterations(Answer when applicable). lLp aw Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this B and f ealth. Signed Date Application Approved by Date 46�_�� Application Disapproved for the following reasons Permit No.0?4fe l.- Date Issued /�o .. 41 i .z THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance F tTHIS IS TO CER FYI that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded( ) Abandoned at has been constructed'in accordance with the provisions of Title 5 and the for Disposal System Construction Pertnjfi ©9D/;' dated/12' `Z,? 1 7 Installer Designer The issuance of this permit shall not be construed as a guarantee that the systnt will Onction as d�ees�iign.ed. ~4 Date ���1 �� r 00 1 Inspector � '11 `4 No. 4VA0_/1 Fee` THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS xigpogal *pgtem Congtruction Permit Permission is hereby granted to Construct( )Repair( (/ Upgrade( )Abandon System located at Z q ���_s /�/�Y �✓�'fir° and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must becompleted within three years of the date of thi q Date: 460� Approved Page 10 oT l l ' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 24 JANES WAY OSTERVILLE,MA 02655 Owner: H LPERN Date of Inspection: 11/19/01 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.Locate where public water supply enters the building. 'I ^ 14 M W Y 4i [C TOWN OF BARNSTABLE LOCATION SEWAGE # ASSESSOR'S MAP LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY n� i\ep LEACHING FACILITY: (type) ` ' (size) NO. OF BEDROOMS BUILDER OR OWNER PERMITDATE: (4(�l_,.I 1 uo i 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 1,aching facility) (� n^ Feet Furnished by I � beck. Z3 d G I ,® a 3 a�� COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS A DEPARTMENT OF ENVIRONMENTAL PROTECTION Z W rr. ,^ J F ...:$.,£fi£n".,.• yti S' Q ' V� sN TITLE 5 F OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 24 JANES WAY OSTERVILLE,MA 02655 l�� _61-1 l�-k aQ10 � �( Owners Name: HOLPERN ., .. Owner's Address: 24 JANES WAY OSTERVILLE,MA 02655 M Date of Inspection: 11/19/01 ki Name of Inspector: (please print)`#° JOIJN GRACI RECEIVED x � Company Name: SEPTIC INSPECTIONS Mailing Address: PA BOX 2119 TEATICKET,MA.02536 DEC o ZoU� { ; Telephone Number: 508-564-6813 FAX 508-564-7270 TOWN Of: DLt EA CERTIFICATION STATEMENT 3 I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: _ Passes r X Conditionally ses 4 _ Needs Furth valuation by the Local Approving Authority t Fails r' Inspector's Signature: Date: 11/19/01 The system inspector shall submit copy of this inspection report to the Approving Authority(Board of Health or DEP)within sY' 30 days of completing this inspec ion. 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. Notes and Comments SYSTEM CONDITIONALLY PASSES TITLE V INSPECTION.D-BOX IS CURRENTLY BROKEN.RECOMMEND 5, PUMPING NOW AND THEN EVERY-TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. , ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This G> awe inspection does not address how the system will perform in the future under the same or different conditions of use. Sk r a Page 2 of 1 I t OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 24 JANES WAY OSTERVILLE,MA 02655 Owner: HOLPERN Date of Inspection: 11/19/01 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. ti Comments: SYSTEM CONDITIONALLY PASSES TITLE V INSPECTION.D-BOX IS CURRENTLY BROKEN. RECOMMEND PUMPING NOW AND THEN EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. B. System Conditionally Passes: X 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. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain: . x x n/a The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: n/a n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed t 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 Yµ. _ obstruction is removed X distribution box is leveled or replaced ND explain: n/a n/a .The system required pumping more�'than 4 times a year due to broken or obstructed pipe(s).The system will pass K inspection if(with approval of the Board of Health): broken pipe(s)are replaced - _obstruction is removed r ND explain: n/a - x eo . Page 3 of 1 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS ` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 24 JANES WAY OSTERVILLE,MA 02655 Owner: HOLPERN , Date of Inspection: 11/19/01. ' cif C. Further Evaluation is Required by the Board of Health: ,1 _ 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 f '; 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. ~ '•: Y;.. _ 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'4ank 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 n/a ;} "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 1 "fit ,e 3. Other: n/a I ` 1 A y ti zr41ti� �Q�: r Page 4 of 11 y. i OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 24 JANES WAY OSTERVILLE,MA 02655 Owner: HOLPERN Date of Inspection: 11/19/01 ,µ D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all-inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool aYx X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ' sl A AF- X Liquid depth in cesspool is less than 6"below invert or available volume is less than'/2 day flow X Required pumping more than 4 times in the last year NAM—due to clogged or obstructed e s .Number of times q P P g Y gg P�P ( ) pumped nLa. ' X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool,or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy,is within a Zone 1 of a public well. ; X Any portion of a cesspool or privy is within 50 feet of a private water supply well. h X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with yP no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP ;� certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free ' V'V` from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be Fk attached to this form.]. (Yes/No)'The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. i E. Large Systems: , To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: P , The following criteria apply to large systems in addition to the criteria above ' yes no X the system is within 400 feet of a surface drinking water supply r x X the system is within 200 feet of a tributary to a surface drinking water supply ` "t A X the system is located in a nit`r'ogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped , Zone II of a public water 96pply well ; F If you have answered"yes to any question in Section E the system is considered a significant threat,or answered z "yes" in Section D above the large�9ystein 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. 'a Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .0 PART B CHECKLIST Property Address: 24 JANES WAY OSTERVILLE,MA 02655 Owner: HOLPERN Date of Inspection: 11/19/01 y Check if the following have been done. You must indicate"yes"or no as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health t X Were any of the system components pumped out in the previous two weeks X _ Has the system received normal flows in the previous two week period? F}` X Have large volumes of water been introduced to the system recently or as part of this inspection? X Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelfing,inspected for signs of sewage back up? .. I X _ Was the site inspected for signs of break out? X _ Were all system components,excluding the SAS, located on site? t; X _ Were the septic tank manl ales uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? `A ` X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems The size and location of the Soil Absorption System SAS on the site has been determined based on: G Yes no ... X _ Existing information. For example,a plan at the Board of Health. ` X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] r f Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS :: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C <, y . SYSTEM INFORMATION Property Address: 24 JANES WAY OSTERVILLE,MA 02655 ;..' Owner: HOLPERN } Date of Inspection: 11/19/01 sy " FLOW CONDITIONS RESIDENTIAL +>. Number of bedrooms(design):2 Number of bedrooms(actual): 2 ' DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):220 Number of current residents: 1 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes'.or no): NO i Seasonal use:(yes or no): NO Water meter readings, if available(last 2 years usage(gpd)): n/a Sump pump(yes or no): NO Last date of occupancy: n/a ' t, COMMERCIAL/INDUSTRIAL '.,. Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd {"' Basis of design flow(seats/persons/sgft,etc.): n/a r� Grease trap present(yes or no): NO �k F Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a :r.•v'Y GENERAL INFORMATION Pumping Records -a Source of information: n/a Was system pumped as part of the.inspection(yes or no): NO If yes,volume pumped: n/agallons--How was quantity pumped determined?n/a Reason for pumping: n/a TYPE OF SYSTEM y' X Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy � t _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained fromF' system owner) _Tight tank Attach a copy of the DEP approval Other(describe): n/a Approximate age of all components,date installed(if known)and source of information: - 23 YRS s Were sewage odors detected when arriving at the site(yes or no): NO t Page 7 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 24 JANES WAY OSTERVILLE,MA 02655 Owner: HOLPERN Date of Inspection: 11/19/01 lu BUILDING SEWER(locate on site plan)` t Depth below grade: 18" Materials of construction'_cast iron _40'PVC Xother(explain):20 PVC Distance from private water supply well or suction line: n/a ;VR Comments(on condition of joints,venting,evidence of leakage,etc.): r; TOWN WATER ry wy SEPTIC TANK: X(locate on site,plan) Depth below grade: 12" 5A Material of construction: Xconcrete metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) .. Dimensions: 1000G L 8' 6" H 5' 7"'W 4' 10"" Sludge depth: 6" Distance from top of sludge to bottom of outlet tee or baffle:28" Scum thickness: 12" Distance from top of scum to top of outlet tee or baffle:4" Distance from bottom of scum to bottom'of outlet tee or baffle:8" f 3 How were dimensions determined: MEASURED ` Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): SEPTIC TANK IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.RECOMMEND PUMPING NOW AND THEN EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. ' f: GREASE TRAP:_(locate on site plan) ¢ : Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Y Distance from top of scum to top of outlet tee or baffle: n/a t Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a 4: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related a -` to outlet invert,evidence of leakage,etc.): F n/a .. r � S i 7 Page 8 of I I °; r OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 24 JANES WAY OSTERVILLE,MA 02655 k �� Owner: HOLPERN Date of Inspection: 11/19/01 r TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction: concrete metal fiberglass_polyethylene_other ex lain : n/a ' Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A 4'i Alarm level: N/A Alarm in working order(yes or no):NO " Date of last pumping: n/a I Comments(condition of alarm and float switches,etc.): ; 1 n/a DISTRIBUTION BOX:X(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): D-BOX IS CURRENTLY BROKEN .tti PUMP CHAMBER:_(locate on site plan) ' Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO ' A#�t" Comments(note condition of pump chamber,,condition of pumps and appurtenances,etc.): n/a � . S p' kl D} n Page 9 of 11 $. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 24 JANES WAY OSTERVILLE,MA 02655 Owner: HOLPERN Date of Inspection: 11/19/01 3f yI SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: P _ n/a Type 1000 GAL 6' X 6' leaching pits, number: 1 n/a leaching chambers, number: n/a t z� n/a leaching galleries, number: n/a n/a leaching trenches, number, length: nla . n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a innovative/alternative system Type/name of technology: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): ';. LEACH PIT IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.PIT HAS I' OF LIQUID IN IT NOW AND HAS NEVER BEEN MORE THAN 3/4 FULL.BOTTOMI S AT 8'. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a . Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO } Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) 3 Materials of construction: n/a Dimensions: n/a Depth of solids: n/a k Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): y. n/a . J"" Page 10 of 11 u. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 24 JANES WAY OSTERVILLE,MA 02655 Owner: HOLPERN Date of Inspection: 11/19/01 w SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. . .. A .:_ oeck 00 AA iry � lb a�N z (3u F ::r7 , r Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 24 JANES WAY OSTERVILLE,MA 02655 Owner: HOLPERN Date of Inspection: 11/19/01 r: SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 12+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-1f checked,date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a ` NO Checked with local excavators, installers-(attach documentation) YES Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: ` GROUNDWATER DETERMINED BY AUGER- 12' NO WATER ENCOUNTERED-BOTTOM OF PIT AT 8' ' ' 98, r . • I1 LOCATION ' -S SF-\,N ►G4E PERMIT UO. IWSTaLLER5 I & AE � ADDRESS BUILDER 5 ►.1 &MF- �- ADDRIe SS — — CAS�'� L�- 1,c/2,L�o I?e.,rUs — — — — DNTE PERWT ISSUED D ATE COMPLI &MCE ISSUED : — — — L-� �_ V`� � J. 4 d I�7 i (/ i '` � - 0 ^( ��� �'3 ��' �► �_�. I - No...... . ... ........... THE COMMONWEALTH OF MASSACHUSETTS BOARD QF HEALTH.,, .._ .. OF.... ..... ................. = -..._....:...--- ----.................. Appliration -for 43itipoo l Works C onotrurtinn Prriffit Application is herebymade for a Permit to Construct Repair ( ) an Individual Sewage Disposal System L.. ..e or Lot N f O ner ss (� Installer Address �/ d Type of Building Size Lot........................ ....._............... Sq. feet U Dwelling—No. of Bedrooms__________ ____________________________Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building __________________•___...--- No. of persons............................ Showers ( ) — Cafeteria ( ) a d Other fixtures --1e, ----------------------------------_---- .................................................................... Design Flow._____,.5*_(2........................gallons per person per day. Total daily flow................... --___.._....gallons. WSeptic Tank_Liquid capacit�C7a ;allons Length................ Width........-------- Diameter---------------- Depth---------------- x Disposal Trench—No. .................. L___.__........_.__. T ength__._._............. T al le mg area_.__ l�_ sq. ft. Seepage Pit No. `s �� ------------------- II ow t et.......-=--•-•---•- o area------------------sq. ft. z Other Distribution box ( Dosing tank ( ) 4P,6,` to — l k — 74,01 y aPercolation Test Results Performed by------- ------------------------------•---•-•••.....----••......-•------- Date------------------------------------ Test Pit No. 1................minutes per inch Depth of "Pest Pit-------------------- Depth to ground water._-___.--_--._-- �Zq Test Pit No. 2................minutes per inch D pth of Test Pit-------------------- Depth to ground water......---__-_--_-__-_.. W -• •--...•-•--•-••-•••-•-•••-------------•_- -------- O Description of Soil "� ? --- ---=-------- /40- U ------------------------------------------------------------------------------------------------------•-----------------------------------------------------.....------......_........_• -------------- W x ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 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 Article \I of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by th boar of heal i. igned. _ ....... ��� ". �/ D e Application Approved By----- .... �� -� �. - -----•- -------- ---7k--_-7 Date Application Disapproved for the following reasons:.................................... ...•-•-=-•--------.....---.............-••---......••---...----•-••- ------•-•-••---•--•--------•---•---------------------------------•----------------------------•-•-------•----------------•-------•------------------------------------------•--------••----------.-•--- Date PermitNo......................................................... Issued........................................................ Date No. �1 . . FEa...... .......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...0F......f ..........................................I.............................. Appliratinn -for Utipniittl Workii Towitrurtintt Vanift Application is hereby made for a Permit to Construct (y or Repair ( ) an Individual Sewage Disposal System ---¢-- �'-----------'�---/-.---- ----- li. "''� ,/- ---•-•-• ----- ..............•-•-. Lo��n-Address /7 or Lot No. -•-- ............2�......................................... ............................. .................................... ............................................................ ner i AA��ess Installer /� Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) pa, Other—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) a' Other fixtures ___ ________________ W Design Flow.___,__���_6)________________________gallons per person per day. Total daily flow............................................gallons. W Septic T:,nk—Liquid capacity------------gallons Length................ Width.--------------- Diameter................ Depth................ x Disposal Trench—No- ----_------��------------- T� ....... ._..__....._ T 1 lea ng area...... _G.�q. ft. Seepage Pit No.,.._-./ _ - a e -------------------- De ow t et a¢` area----_ ..........sq. ft. z Other Distribution box ( ��/ Dosing tank ( ) 0b- G— / lr -7, aPercolation Test Results Performed bY.......................................................................... Date-------------------•--•---------------- a Test Pit No. 1----------------minutes per inch Depth of "Pest Pit.................... Depth to ground water........................ �14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ -• ' j---------•-------------------------------•---- •----------•- ------------ . O Description of Soil --_-_-------lt__t _,'.,-------- �� - 2 G . �: ��'' x -------------------------------------------------------------------------------------------------------------------------------------------------- ------„_------------------------------------------ V Nature 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 Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the boar f health. ,� /J//�Q/L (�/C// �J///�.L' r! ! /%�?°'fi e /��/, f tgned-- _-_--? __., I ' �� ) /� / ` Days Application Approved BY------ G% ---- �_/-' d /Cl G -- .`/.. _- � Date Application Disapproved for the following reasons----------------------------------------------------------------------------------------------------------------- -----------------------------------------------------------------------„----------•----••--------•----••---..,•--------------,,-•-•-----•---•---•-•--•------,---_._...-_...--------......------------ Date PermitNo--------------_-- ................................ Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS 14— BOARD OF HEAL,T .......... 11-Ui-.Z ..OF.....`'....... � G wrrtifiratr of w0lamplianrr THI,F,JS TO CERTIFI� rII,Tha e Individual Sewage Disposal System constructed ( or Repaired ( ) � -------------------------I--nstalle- - ..................- -----• -- --------------------------•-••--••-•--••-- r -- --------�------------- ---- ..................................------- has been installed in accor dance with the provisions of A i�r )XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit No._��,__ l z,.._._..__. dated--.._���_------���_................... THE ISSUANCE OF THIS CERTIFICATE SHALE, NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTIO-N SATISFACTORY. t DATE............... --------- Inspector .....................................' ` " THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALT e:_..._ f 'lf� ........O F... ..... . . No. FEE........................ invnii , nrkii Tong Fur 'bit rrntit Permission ?,/Or x granted---- ------�- ----------------- ------------------•-•------------....------.....---•-•---•--....- to Construct Repair ( an Individu Sewage Disposals stem at No..,---- 5 ___ --- -------- --------- --%'-----------------------___.------ ................. Street �_ as shown on the application f r Disposal Works Co truction Pe m• No,-__.f�__ _._•.._____ Dated_-___7=./%__ _ _S,p_........... Board of Health DATE.........-•••- - ------�� _------------ FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS np of • y ��3K - "X P��' �9 Af A 1, y Z I T,11 Tq St s 3a r Olt ,�•,�� ark `�gr, x ..: -. .- --l*1 F ,,`."Y'�.1.•.•'L'4T.'J.U� � � .�/ � i 3 �,.. '� 'e �•,r�`�p� �rw�' leei/ ``J �j o 4 �•F`W L'r A?/.a,C'�^�••'7 E, © V r ¢ _ �3 v�`` !.:"4 a�, ._'�F zj jr �✓ Y ( to r rii J}UM�"` 5 > TO- ; ,'tom �/Q�tir'/�.I'�C�^M7 C..�.^✓'.� - � a kr�'�{F 1 r o i•- t`56�T i , L ' � r �,c.9 i✓n'y'" �4.�ur..,i :�:/Z 2.] �, s ,. °. •�/'°i e, : �"'' S tz a n'"�.�xi r`�P wL�X�� `apY urNa 0SY'' Cr/3,T7"/�i� TM�iF 3'7sd4 �fe/e��/.�/eFi y ' f�b4�!uti/ Read/ rAello e®l.AQA✓ /W d®C�7'�� ®Al 7^6I� z ,; w[ �yK<4� z' x�a[xc p� ,,�► ��ir�` @ i�`�� �.r' �.. '. y�ev1�Lge-� p CAW I C"®.As�,✓tA�'i6�L�A.� w�9a'�/N f'i'& 0 PWA.1 OV'�' 9''r A: O AkIVr H. Y o QJAIA �rf W, 2634 tl AlfOLol L,.00LI,TION 5EW&C-.4E PERMIT UO. kA t k5-T`v lNST�LLER•5 1J�NlE � ADDRESS BUILDERS QDMF- ADDRESS DATE PERMIT ISSUED D A.TE COMPLI &KICE ISSUED : - - - ��� �� ^ �. � b � �. r . �� ��: .� } �,' �� , . j No.... ---•-•--• Fu$ . ................... THE COMMONWEALTH OF MASSACHUSETTS • BOARD OF HEAL H_ OF..... .......................... .......................... Appliratiott -fur Biiipuml Worbi Tomitrurtiott Vrrntit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal S st a f .. •. ca' I ress I Lot No. I ... ............ ...... ..................... ... ............. .... .................•...... = ............-- r Owner / p. Address Installer Y Address dType of Building ��jj Size Lot----------------------------Sq. feet U Dwelling—No. of Bedrooms.--__®` ................... .Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures W Design Flow---------13-0......................$lons per person per day. Total daily flow............. .............gallons. WSeptic Tank—Liquid capacit, ons Length................ Width....... ........ Diameter................ Depth-----_--_-.--... x Disposal Trench—No_____________________ Width ._ _.___..______ Tota th........... ....... T le ing a�rea...��_�sq. ft. Seepage Pit No.._._ � �Drerformed Dept n _ ....... " o ing area------------------sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results by---------------- ......................................................... Date----•---------------------------------- a Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................niinutes per inch Depth of Test-Pit.................... Depth to ground wate _....-.-.-_.--_---_/... tx ... �f ....... .. l � O Description of Soil ..... __._ _ — ✓r J x -- ---- -------------------•-•-- --------------_---------------------------------------------------------------------------------------...-..------------------------- ----------------------------------- .---------------- U Nature 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 Article XI of the State Sankary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. - ��/ ... Date Application Approved BY------------ �� 'C• , /� --------�------ -� Date Application Disapproved for the following reasons:......................................................................................--------•-----•----------- ••...-----•••-•..............•--•-----•--•--------------------•-------------•--•--•----•---•------------------------------------.---•-.----.-------------•---------------------------------------------- Date PermitNo........................................................ Issued........................................................ Date fr� ............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALT Appliration -for Uigpoittl Workii Tonitrnrtion Prrniit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal r - --� O G yst _ at .............................. -----------•-•......---•-- iLocati ress /� Lot No. I •----- ---------•- ..... •.. ............. ........ ................................ . ......---•---•- -----• •.... •---.....---- W C Owner Address - o •... -----•----......--•--•--...--- Installer Address <11 Type of Building ` Size Lot__--------------------------Sq. feet U Dwelling—No. of Bedrooms------ -----------------------------------Expansion Attic ( ) Garbage Grinder ( ) a4 Other—Type of Building -----_-___________________ No. of persons............................ Showers ( ) — Cafeteria ( ) al Other fixtures . W Design Flow-_--___._-:�7��....................... Ilons per person per day. Total daily flow................ __.a_-----------gallons. x Septic Tank—Liquid capacit/e' alIons Length---------------- Width.-------........ Diameter-----....-.----- Depth.......... ...... Disposal Trench—No- ---- - Width_ a r �/ ng area...__.e:�'_-Z_ q. ft. .... Seepage Pit No.......,L(Ll. iam � `De nth Total- 1-th`- -T o T lea ping area------- ----------sq. ft. z Other Distribution box ( ) Dosing tank ( ) U,/� (� ''1P-74; . aPercolation Test Results Performed by-------- ----------------------------------------------------------------- Date-------------------------------------... Test Pit No. 1----------------minutes per inch Depth of "Pest Pit...----.-____-___--- Depth to ground Water_------. ----.----. - fs, Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water--.--.-------.-----.. -- `r� :_ ' :�--- fir. ..._`.... :: fI �/. /�. O Description of Soil.---••--.....'2 •---.c)...._... "" - ® �/ �t '-r�..... x ---------- ----- W U Nature 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 Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has beenissued by the board of health. f fined/ ' .. � t �'/ `! - V / - > = G Date / Application Approved BY--------- j-��'!-!�f-••------ ------"-�'����-- -- -=-��-�=-- � ---------� -- Date Application Disapproved for the following reasons:---------- •----------•------------•-•---•-------------------------•--•-•------------------•------------------ ................•-••-------------•----------••---••-••-------•-•••-•------•---•-•-•--- •-•-••••--------....._.........------•----...............------------.._...-•--------------••-•---------.....----- Date PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALT _ � r /l .f�+--.........OF..`/ .. n................................. . .................... x1rdifirate of "JITotttphaurr THIS I TO CERTIFY, T� the/I R&%jqual Sewage Disposal System constructed ( or Repaired ( ) by / ...................................... ...................... i Installer at............ ...---'-%----.._------ --- -- '.- -9- �E v nnce with p has been installed in accord<t ' h the rovis�`6ns of ArVe �1'I of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.-. __.e-------- j_ ......... dated--...__ _� 1/ ._-_. G....... THE ISSUANCE OF THIS CERTIFICATE SHALL, NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE--- ------�• ------- ----- ---------- �'` Inspector --- €-.. 'lr ' s -b s�... ....... ... THE COMMONWEALTH OF MASSACHUSETTS BOARD HEAL O. �?... FEE.,._- .. !,1101rl tit ----. Permission is he ranted ----------- = -------------- ----------•------••-•----•---.----- g to Construct ( or Repair ( ) an Individual ewe Disposal System_ at No. r" -------- ri�'f .----•-----•-.-- .... ----------------------------------------•-.--------.--- .� , Street -- --- --- as shown on the application KO Disposal Works Construction Permit No 1-__-__--.--- Dated....._.._` ..... ............ -'` ,!, ®o- DATE----•------- ---- -------- -- --------------------•............ Board of Health 1 FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS r tc Rl r { s A r j h a2�ct<vr,�yy J $ � A W 01 MIS +x k 3 4fi 7 • � A i• a v'g����.'a+��e�6r ®' //!/4 'r G.c> c r" �..fir•✓ --� l �p , �E /y� '�C' /A7 a iaF'r<, ,� AW����� �6',EP�"/A�'1'°' 9"�/AgY"' �� �N/L8�/it/� ,� a...- u.�r��'A 'n�`'.G`> . � ��,�•• �y:. �#� ► d+Ed+t,/ 'rA-eo4' AwAti.A*" /V 4000* C CA/ rJW s �f�n� COA.OWC�ATA-f 7-0 sw lie R sr: p ARN J.�`� g •r ��"� r � 9 /q ® /� � ®e �y.ds a��•w.r/. �i a`,^®4.17W 6i o... icr�®C/7'Ne ",QSZ. PR, t u . 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