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HomeMy WebLinkAbout0047 REBECCA LANE - Health 47 Rebecca Lane Osterville P A,.�. 146 060 z t fl i No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 0(ppYication for ;Digpogat *pgtem Cori.5truction 3dermit Application for a Permit to Construct(4Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.f'�b7 e''eCrCcL Assessor's Map/Parcel1,4,n e Owner's Name,Address and Tel.No. (// ®S4eru;)1-e j/ 9`�iG Qc��rt�sS / 16 6 d�— � Installer's Name,Addressan(G 1131tANCO Designer's Name,Address and Tel.No. 350 Main Street A11-4 W. Yarmouth, MA 02673 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 �r�l? gallons per day. Calculated daily flow 56j" gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank /,o&9 Type of S.A.S. rn i 104hrx AA iv a,'L ems) Description of Soil Nature of Repairs or Alterations(Answer when applicable) Z n S+A// 1 0° nClfiA4ars (mAx ;n, i.2rrs) LJ1 Y ' Siv11e 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 Board oyf ealth. Signed _ Date Application Approved by - Date Application Disapproved for the following reasons Permit No. 15, 7 Date Issued No.�b �© � Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS ZIpprication for Zi.5pooar *pztem Conz uction Permit z� t Application for a Permit to Construct(Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Address-and Tel.No. . y'1 l�eheccce_ !�l n e Owner's Name,Addres ' 05ferU_i_II �r�c Qa�SAeS-S Assessor's Map/Parcel /[J!/ N Installer's Name,Address,Ad&*4ANC0 Designer's Name,Address and:Tel..No. 350 Main Street W.Yarmouth, MA 02673 - 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 361-1, gallons. Plan Date Number of sheets Revision Date ' f Title Size of Septic Tank /0A-0 Type of S.A.S.. r r lm Q k e 2 c t) Description of Soil Nature nnot Repairs or Alterations(Answer when applicable) /}3 f n/� 1 - O• /3 o x Ln *;)+rA4,5r3 (M,1xinn � > , r.s� S- h q J]Ldac Date last inspected: Agreement: The undersigned agrees to ensure the construction and mainten an 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 Board of Health. Signed .� Date //- I- 9/ Application Approved by Date�� C Application Disapproved for the following reasons .f Permit No. t Date Issued ——— THE COMMONWEALTH OF MASSACHUSETTS 5. BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO.CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired Upgraded( ) Abandoned( )by at �� �r �.��� /,��, /�r-E u.'/�i has been constructed in accordance �' - W _ with the provisions of Title 5 and the for Disposal System Construction Permit No dated 4t'w A Installer Designer The issuance of this permit shal jot bbec nstrued as a guarantee that the syste wi�1 .unction as designe el Date ��..+ r► r`� �. r,.i Inspector PP ---------------------------------------- No. b Fee So — ! THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS �tg oar pOtetn Construction Permit Permission is hereby granted to Construct( )Repair(✓)Upgrade( )Abandon( ) F System located at '5e;? oe� 'e- 44,-e a���4��,L�c and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to complyrwith Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this p it. 1 Date: Approved bL� s TOWN OF BARNSTABLE OCATION 6 / /& eee, 14. SEWAGE # K" OG VILLAGE,aiAR-eVi e ASSESSOR'S MAP & LOTS INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type t (size) NO.OF BEDROOMS BUILDER OR OWNER 5,4K 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 Facility(If any wetlands exist within 300 feet qf leachin faci 'ty) Feet Furnished by • � I v.x 4 � 1 CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) hereby certify that the application for disposal works construction permit signed by me dated i/ 9 , concerning the property located at L , meets all of the following criteria: There are no wetlands within 300 feet of the proposed septic system There are no private wells within 150 feet of the proposed septic system v The observed groundwater table is 14 feet or greater below the bottom of the leaching facility There is no increase in flow and/or change in use proposed ✓• There are no variances requested or needed. SIGNED: l. a DATE: LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. o 350 Main St. a W. Yarmouth, MA 02673 a 775-6264 Division of Canco Energy Corporation Septic Services a Pumping a Installation 0 0 sys+�w� 0 ^U) SEPTIC SYSTEM DESIGN F .. DgD A(S AT .. GAL/DAY/BEDMOM = .. GAL/DAY SLPTIC T GAL/DAB' x 2 DAYS GAL USE _.1 _ GALLON SKPTIC TANK (EXISTING) LEACHING AREA-0 USE 8 INpILT'RATORS AXIMIZER CHAMBERS WITH 4' OF STONE ALL AAWND (W x if z Z DEEP) St DE AREA.- LSO + 11L2 x.2 = 164 SJ' (.74) CAL/DAY EOM ARZA- ST x rr = 330 S (.74) _ Z44 GAL/DAY CAPAC GAL/DAY COMMONWEALTH OF MASSACHUSETTS OCT 3 0 Z002 EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAI S DEPARTMENT OF ENVIRONMENTAL PROTEC II(jWVN`-';F E"`""TASI E i HEALTH DCPT. > s9 �E_ i o ,� e,•• OCT 3 12002 ITOVIJN OF BARNSTABLE TITLE 5 HEALTH DEPT. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORMi- PART A CERTIFICATION MAP PARCEL : O (P Property Address: 47 REBECCA LANE OSTERVILLE,MA 02655 M146 P060 L47 LOT Owner's Name: ERIC BARSNESS ' Owner's Address: 47 REBECCA LANE OSTERVILLE,MA 02655 Date of Inspection: 10/8/02 Name of Inspector: (please print),I ; JOHN GRACI Company Name: SEPTIC INSPECTIONS I ► Mailing Address: 'jR.O"s BOX'2119 TEATICKET,MA.02536 CO Telephone Number: 508-564-6813 FAX 508-564-7270 CERTIFICATION STATEMENT ` 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: X Passes ""' :•, _ Conditionally` - sses. _ Needs Furth valuation by the Local Approving Authority _ Fails Inspector's Signature: Date: 10/8/02 The system inspector shall submit copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspect on. 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 copied sent to ithe buyer, if applicable,and the approving authority. Notes and Comments SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE: ****This report only describeikdo.ndilioiis at the time of inspection and under the conditions of use It that linj�.'1'11ls inspection does not address howlahp system will perform in the future under the same or different conditions of use. f,, T�,1� 5 Incirrfinn r'nrm h!IS/�(1(1fl I Page 2*of OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 47 REBECCA LANE OSTERVILLE,MA 02655 M146 P06O L47 Owner: ERIC BARSNESS Date of Inspection: 10/8/02 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X 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: SYSTEM PASSED TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. B. System Conditionally Passes: One or more stem components as described in the"Conditional Pass"section need to be replaced or repaired.The system, _ Y P upon completion of the replacement.or ,,repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,NIND).in the for the following statements. If"not determined"please explain. 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 pipe(s)or due to a broken,settle&br uneven distribution box. System will pass inspection if(with approval of Board of Health): _ broken pipe(s)are replaced _`.obs'tructioil is removed _ distribution box is leveled or replaced ND explain: n/a Y. n/a The system required pumping more than 4_times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken;pipe(s)are replaced _obstruction is're`moved ND explain: n/a Page 3•of I I OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 47 REBECCA LANE OSTERVILLE, MA 02655 M146 P060 L47 Owner: ERIC BARSNESS Date of Inspection: 10/8/02 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 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 septictank.and SAS and the SAS is within a Zone I 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'deterimine distance n/a "This system passes if the weil'' te'r analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: Page 4 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property ert Address: 47 REBECCA LANE OSTERVILLE,MA 02655 M146 P060 L47 Owner: ERIC BARSNESS Date of Inspection: 10/8/02 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 X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool 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 NOT due to clogged or obstructed pipe(s).Number of times pumped 2002 BY OWNER. X Any portion of the SAS,cesspool or privy is below high ground water elevation. _ X Any portion of cesspo6F'o`"'r,0 vy 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 I of a public well. _ X Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ 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 no acceptable water quality analysis. IThis system passes if the well water analysis,performed at a DEP certified laboratory,for eoliform 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 forma (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. 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: (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 X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen.sensitive area(Interim Wellhead Protection Area—1 WPA)or a mapped Zone 11 of a public water supply avell If you have answered"yes',';to any question in Section E the system is considered a significant threat,or answered "ves" in Section D above the large system lies f iled. 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 CM It 15.304.The system owner should contact the appropriate regional office of the Department. a Page S of I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 47 REBECCA LANE OSTERVILLE,MA 02655 M146 P060 L47 Owner: ERIC BARSNESS Date of Inspection: 10/8/02 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 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? 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? X _ Was the site inspected for signs of break out'? X _ Were all system components;excluding the SAS, located on site'? X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum'? 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: 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 CM 15.302(3)(b)] " ;t 5 Page 6'of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 47 REBECCA LANE OSTERVILLE,MA 02655 M146 P060 L47 Owner: ERIC BARSNESS ' Date of Inspection: 10/8/02 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):330 Number of current residents:3 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(ye s or.no): NO [if yes separate inspection required] Laundry system inspected(yes or no): NO Seasonal use:(yes or no): NO Water meter readings, if available(last 2 years usage(gpd)):Wft- (� _ ( �2 0 0 Sump pump(yes or no):NO U U —Ift7t�� Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL Type of establishment: n/a " Design flow(based on 310 CMR15.203): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no):NO 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 GENERAL INFORMATION Pumping Records Source of information:2002 BY OWNER Was system pumped as part of the inspection(yes or no): NO If Yes,volume pumped: n was.quantity/a�allons�- How q Y pumped ed determined? n/a Reason for pumping: n/a TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(iG.,ycs•,attach previous inspection records, if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained ti om system owner) Tight tank Attach a copy of the DEP approval g , Other(describe): n/a Approximate age of all components,date installed(if known)and source of information: 1977 BY OWNER Were sewage odors detected when arriving at the site(yes or no): NO Page 7 of I 1 OFFICIAL INSPECTI?ON FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 47 REBECCA LANE OSTERVILLE,MA 02655 M146 P060 L47 Owner: ERIC BARSNESS Date of Inspection: 10/8/02 BUILDING SEWER(locate on site plan) Depth below grade: 18" Materials of construction: cast iron X401 PVC- other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting;evidence of leakage,etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade: 12" Material of construction: Xconcrete_metal jiberglass_polyethylene other(explain)a/a If tank is metal list age: n/a Is age c`onfrnied by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 1000 GALLONS" Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle:33" Scum thickness:0" Distance from top of scum to top of outlet tee or baffle:6" Distance from bottom of scum to bottom of outlet tee or baffle: 18" 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 AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERY TWONEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. 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 Distance from top of scum to top of outlet tee or.baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): n/a : 1 i Page 8 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 47 REBECCA LANE OSTERVILLE,MA 02655 M146 P060 L47 Owner: ERIC BARSNESS Date of Inspection: 10/8/02 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(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alann present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): 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 STRUCTURALLY SOU"-. , PUMP CHAMBER:-(locate on site plan) Pumps in working order(yes or no) NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a u Page 9 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 47 REBECCA LANE OSTERVILLE,MA 02655 M 146 P060 L47 Owner: ERIC BARSNESS Date of Inspection: 10/8/02 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type 1000 GAL 6' X 6' leaching pits, number: 1 1NFULTRATORS leaching chambers, number: 3 n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a :innovative/alternative system ,TypQy/name of technology: n/a Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): DID NOT EXPOSE SAS,APPEARS TO BE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. SYSTEM SHOWS NO SIGNS OF FAILURE. INFULTRATORS WERE PROBED DRY. 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 a PRIVY: (locate on site plan) Materials of construction: n/a ^•: Dimensions: n/a Depth of solids: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a 4 Page"10 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 47 REBECCA LANE OSTERVILLE,MA 02655 M146 P060 L47 Owner: ERIC BARSNESS Date of Inspection: 10/8/02 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. 9 q 2-7n A b 3� P;6 U" A Lio Sri So in 0 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(contim:ed) Property Address: 47 REBECCA LANE OSTERVILLE,.MA 02W M146 POW L47 Owner: ERIC BARSNESS Date of Inspection: 10/8/02 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 10+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-If 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'e'xcavators,.installers-(attach documentation) NO Accessed USGS database-.ezplai ul n/a You must describe how you established the nigh ground water elevation: HAND AUGER- 10+FT. tt 017 } 'f a'CAT ION EWA G E PERMIT NO. VILLAGE. INST,ALER'S NAME & ADDRESS B UI'LDE R OR ..OWNER DATE PERMIT ISSUED -DATE COMPLIANCE ISSUED_ /�� ^- � ' "�;f � `, � -__�. ��, .. _ - � r , � w a �' s� �. I ^f�`.�. r / �^ Y' � ' � �). y ' e, �^- �. � 4 .�� �� a :, `� I , , q {J t r I3v•ov - ra a p Fbv,vz�A Trd N . • I ,�E 3EGG� A t la-1, 'ribwl`n-h Its "/o axPA Slor.3 10 � LOCAT'IDI`! OirsVI L. - A`r - Note. 41,I4�6 �I 714A,T -rla C-z P0000 mO4 5ulcbuf,1 a ou cor - .�.� 111.1 QDT •A�, -L'� Ot�.! A1,? A,1'_ `',- e."). .fr�'rGf.', Ai�E�L •►1C� ,.1"r L' T l_I` *, , 1 -Z. r � � -'__.—_—____ -----------' THE COMMONWEALTH OF MASSACHUSETTS `OARD!� F HE� "'77 1 M_. OF..... ... ---------------_---- or Repair an Individual Sew ge Disposal Application is hereby,made for a Permit to Construct W".'7 System 7'00�� re i*n Type of Building Z Other Distribution box Dosing tank —07. . ......... .. oil....:n... ................................&. ....... ................... .... The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisiong of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance h s be n issued b boar of a I Date Date Date � Date ~----------'--'---'---^ - -- No..--•••••••--- ........ ......................... THE COMMONWEALTH OF MASSACHUSETTS BOARD/f HEA . . " .----OF....../� � /✓✓ !" , ---------------------- Appliration -for Bi-gVogal orkii Towitrurtion Prrmit Application is hereby made for a Permit to Construct ( A�®rpair ( } an Individual Sewage Disposal System at: _ ----•-------........................................ -t'.*��"C---1_35illw '" -------------- �,r!'.� .�'c/�s !` -------------- 3 ocation-Address or.Lot No. Owner` f Address W < 1...�v'-•,..-.- . ..ems-F......� �' -'z't �%: '"---••-----------------•------------ Installer Address Type of Building s Size Lot..��i_5..............Sq. feet U Dwelling—No. of Bedrooms.--_--.-_:r:"�________------------------- Expansion Attic ( ) Garbage Grinder ( ) per, Other—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Q' Other fixtures ---------------------------------------------------------------------------------------------------------------------------- Design Flow..........,_'`�__:_o......................gallons per person per day. Total daily flow..._....... _ ______--..-.-.-..gallons. W -�/" . 9 Septic Tank—Liquid capacit�_.________g.�llons Length................ Width................ Diameter...........----- Depth................ xDisposal Trench—No_____________________ W i______-____-__....__ ''_Length-------------------- tal 1p6iing area--------------------sq. ft. Seepage Pit No.----,rf---- to �' "?`-:--_--i e let ___-•---__._.__._ rug area-----r`_6�_sq. ft. z Other Distribution box ( ) Dosing tank ( ) -0 =r�........ ' �2 —7G 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 g ound w ter--..-.-..-_-_--.---_-. ------------ x � _ - ---- •---- .•-• ................................ Description of oil . � --- ----------- ------ ---------------- ......................>------ ---- jW 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 Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board.of healAl ..,%Signe -- ---------------------------- Date Application Approved BY �� -.�------------ ����..G - �-h Date Application Disapproved for the following reasons---------------------------- ---------------------------------------------------------------------------------- a ----------------------------------------------------•--.._...------------••---•--•••••••----------------•------------•--•-•------•---•---•------•-------_..__._......----------------------_._..._•••-•- Date PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...................� ...OF.. .......................... uIrrtif iratr of 01.10ntphatur THIS II _'0 CERTIFY, Th SMe,Indyiid� Sewage Disposal System constructed ( or Repaired ( ) by ''-qr----f''==-'--=u`.------ ` .... -- nnstaller 4 at...-----: —'�--C�1. � ... e ----------•--------- -- -------- t�� .................................... has been installed in accordance with the provisions of Ar 7 _of Tl State Sanitary Code as described in the application for Disposal Works Construction Permit No-- ---- ----------7_ ______-_-_ dated-....��/_'-_ _�_-___7�___-_______-__ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE-------"------ ------- ...........7.�'7............. Inspector_ __ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALJH � No. 7 FEE........................ Permission is h granted_._.. —� Xt rYT_-.- �t --_olr-"1rutit ------ ------------- to Construct r Re air an�Frtdwidual Sewa e Disposal System atNo. .............. _`�` ' . � ------ - �----- ---------- ---...-•---------••------ Str as shown on the application for Disposal Works Construction r t N x_ Dated--- _.. ......................... ` ----------------------------- DATE--L - //,�- ------�-C--CCC---------•- --- ---------------------------------------•-• Board of Health FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS