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HomeMy WebLinkAbout0003 STONE HORSE ROAD - Health y 3 Stonehorse Road. 'Osterville TOWN OF BARNSTABLE LOCATION 3 SEWAGE#71Q10' VILLAGE usrefa: N ASSESSOR'S MAP&PARCEL ILI 2 r ` INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY i')i LEACHING FACILITY:(type) �� �,�/ (�1G±M {�size) /' % ?r 11 NO.OF BEDROOMS 3 OWNER f I_cA a J 5ICt PERMIT DATE: J 4 1 E) 1 Qo�)(_) COMPLIANCE DATE:J!Z aao Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY Q � a3:s' 70 i t FJ70 No. �) Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ' Yes PUBLIC HEALTH DIVISION - T9WN OF BARNSTABLE, IVIASSACHUSETTS �ipYication r -Misposal 6pstem Construction 3permit Application for a Permit to Construct( Repair(V1,14grade( ) Abandon( ) [:]Complete System ❑Individual Components Location Address or Lot No:-''{S7n:0.�q�e � Owner's Name,Address,and Tel.No. Assessor's Map/ParcelCi V11 T n' `/ /4 a ei,/S Jk_ ' c ' Installer's Name,Address,and Tel No. Designer's Name,Address,and Tel.No. LTk A,1? TADS s -y�-�/,S"3 y ✓�. �, Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 350 gpd Design flow provided gpd Plan Date Number of sheets / Revision Date Title 1 Size of Septic Tank �jc15 rrrvr Type of S.A.S.�l,&n) C/1C4+ Lta ~Description of Soil Nature of Repairs or Alterations(Answer when applicable) )S+-e, jC. Vex 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 Certificate of Compliance has been issued by this Board of Health. Sign Date // Application Approved by Date alologaa Application Disapproved by Date for the following reasons Permit No. Z:0 3 Date Issued t Z�7,ozoo V r� q f `v No. �f � J t t Fee THE COMMONWEAH OF MASS% ACHUSETTS Entered in computer: LT Yesr�J '• PUBLIC HEALTH DIVISION - TgWN,OF BARNSTABLE, MASSACHUSETTS 4plicatlon for Misposal *pstem Construction Permit 'Application for a Permit to Construct/Repair V u ade Abandon ( pgr ( ) ( ) ❑Complete System ❑Individual Components Location Address or Lot No-jQ ;���o 'j `' Owner's Name,Address,and Tel:No.. i �lC Vt Q / uNt°tlSe�1 Assessor's Map/Parcel !y a Installer's Name,Address,and Tel.Ao. Designer's Name,Address,and Tel.No. Type_of Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) k Other'` Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd - Plan Date /"Jo q!2 c,re.a Number of sheets / Revision Date Title ` '� ✓; )) }} Size of Septic Tank 5x rs�1 Type of S.A.S. Description of Soil V Nature of Repairs orAlterations(Answer when applicable) .a,,,:f O V30y 'si` 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 Certificate of Compliance has been issued by this Board of Health. t Signed, r �'"""_-- , Date /1,12 Application Approved by _ _ .,e Date / g/ -;W> Application Disapproved by / ,F _• _� , Date V ^" for the following reasons Permit No. zo;7(7) 3 C1 i Date Issued 17-A A 2ka g THE COMMONWEALTH OF MASSACHUSETTS , BARNSTABLE,MASSACHUSETTS Certifitate of Compliance THIS IS TO CERTIFY that the On-site Sewage Disposal system Constructed Repaired Upgraded > g P Y ( ) P ( 1� ( ) Abandoned( )by_ ✓y* , �.,rs ,.�r at S 4�,sy«'1�r>re�r► r� r:k s I I has been constructed in accordance i with the provisions of Title 5 and the for Disposal System Construction Permit No.7,??V-'31 1 dated ! J P n Installer;pt %T 1 .3 -Trr_ Designer y- � �utr•C t r w #bedrooms'—_! Approved design flow '33 q gpd The issuance of this permit shall not be construed as a guarantee that the system will f lnction•as designed. Date 1 J Inspector _ __._.. __.. _ __-_ _ __ __ _.._.._.. ___..-- -__ - ... .___ _ __. cc _ .�--- No. � � "' J q Feel►'�+7 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC.:HEALTH DI:VISION-BARNSTABLE,slO�IASSACHUSETTS r Disposal �6pstem Construction Vermit Permission is hereby,granted to Construct( ) Repair Upgrade( ) Abandon( ) f System located at fe r and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit Date t Approved by -ra►+' ', .�--s- - _""-�, _ Town of Barnstable Regulatory Services Thomas F.Geiler,Director" MAS& _ Public Health Division 167q. Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 t Office: 508-862-4644 Fax: 508-790-6304 Date.:Z,Z,l / �,a Sewage Permit# p i� -di l Assessor's Map/Parcel L.2 // Installer&Designer Certification Form Designer < , � Installer: Address: C� "�JG�� Address: On *((dtel) A ,�. f, ,:f nrr;_ was�issued a permit,to install a (installer) septic system at 3 i t (fA apse based on a design drawn by 'N&v by 14:71-C111-lt y�GQ��, t-S (address) �Sp-eC�C;'4 4y��Q1 -,-dated (designer) I certify that the septic system referenced above was installed substantially according to the:desi y g -the-design, which may include minor approved changes such as lateral relocation.of the distribution box and/or septic tank. Stripout (if required) was inspected and the soils } were found satisfactory. certify that'the.septic system referenced above was installed with major changes (i.e. greater than 10'_4ateral relocation of the SAS or any vertical.relocation of any component. of the septic system):but in accordance with State &Local u -Lions. Plan revision or certified as-built by.;d'esigner to follow. Stripout(if rP- -cted and the soils were.foun&satisfactory. OFMAs DAVID %(Installer's Signature) g b. 4 f ` Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 3 Stone Horse Road ' Property Address i ;a) Thomas Grondin .e Owner Owner's Name information is required for every Osterville Ma 02655 6-23-15 =^ City/Town State Zip Code Date of Inspection page. Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: ` # /O 9-7(-9 key to move your cursor-do not Matthew F. Gilfoy use the return Name of Inspector key. B&B Excavation ICI Company Name 14 Teaberry Lane Company Address Sandwich Ma. 02644 City/Town State Zip Code (508)477-0653. S113640 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 6-23-15 In ctor's Signature Date, The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage pisposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3 Stone Horse Road Property Address Thomas Grondin Owner Owner's Name information is required for every Osterville Ma 02655 6-23-15 page. City/Town State Zip Code . Date of Inspection B. Certification (cont.) s 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 31.0 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes:' -.. ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. . The septic tank is metal and over 20.years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass, inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic-tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): . t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts ' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3 Stone Horse Road Property Address A Thomas Grondin Owner Owner's Name information is required for every Osterville Ma 02655 ° 6-23-15 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in.the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if,(with approval of Board of Health): ❑. ' broken pipe(s) are replaced ❑. Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced El,,Y ❑: N ❑.ND (Explain below): " q ❑ 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): 3 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 3 Stone Horse Road E . Property Address Thomas Grondin Owner Owner's Name information is required for every Osterville Ma 02655 6-23-15 page. Citylrown 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 El ® due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official' Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 3 Stone Horse Road Property Address Thomas Grondin Owner Owner's Name information is required for every Osterville Ma 02655 6-23-15 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the 1ast year NOT due to clogged or obstructed pipe(s). Number.of times pumped. ❑ ® Any portion of the SAS, cesspool or privy is below high ground waterelevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or ❑ ® tributary to a surface water supply. ❑ ®' Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow.of 2000gpd 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 mustserve a facility with a design flow of 10,000 gpd to 15,000 gpd. , x: 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 b If you.have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 3 Stone Horse Road Property Address Thomas Grondin Owner Owner's Name information is required for every Osterville Ma 02655 6-23-15 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the'owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® E Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with. information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ' ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)], D. System Information 'Residential Flow Conditions: Number of bedrooms (design): ._ 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 549 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M ,•''r 3 Stone Horse Road Property Address Thomas Grondin J Owner Owner's Name information is required for every Osterville Ma 02655 6-23-15 page. Citylrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: Does residence have a garbage grinder? " ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection , ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, last 2 ears usage d see below 9 ( Y 9 (gP ))�' Detail 2013-67,000gallons 2014-58,000gallons .Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR,15.203):. Gallons per day(9Pd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes '❑ No 'Industrial waste.holding:tank present? - [-] :Yes ❑ No -Non-sanitary waste discharged to the Title 5 system? - ❑ Yes.[] No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form <o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3 Stone Horse Road Property Address Thomas Grondin Owner Owner's Name information is re Osterville Ma 02655 6-23-15 wired for every 4 State Zip Code D f Inspection Cit /Town S ate o page. Y P D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): �. - I General Information Pumping.Records: Source of information: pumper driver . Was system pumped as part of the inspection? ® Yes ❑ No 00 If yes volume pumped: gallons How was quantity pumped determined? tank size Reason for pumping: pumped after inspection for maintenance Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 3 Stone Horse Road Property Address Thomas Grondin Owner Owner's Name information is required for every Osterville Ma 02655 6-23-15 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: 1992 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grader 1'6" feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): At time of inspection building sewer appeared to be in good working order no sign of leakage. Septic Tank(locate on site plan): 10 Depth below grade: t feet Material of construction: ® concrete . _❑ metaIr ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: • yea rs- m li n ? h fcertificate) Yes No 'Is age confirmed by a Certificate of Co pace (attach a copy o ❑ ❑ Dimensions: 1000 gallon 8 Sludge depth: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GSM ,•'' 3 Stone Horse Road Property Address Thomas Grondin Owner Owner's Name information is required for every Osterville Ma 02655 6-23-15 page. CityTTown State Zip Code. Date of Inspection D. System Information (cont.) Septic Tank(cunt.) r , Distance from top of sludge to bottom of outlet tee or baffle 2811 Scum thickness 3 6„ Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 15„ 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.): At time of inspection septic tank appeared to be in working order,Tees present no sign of back- up.Liquid level equal with outlet invert. Tank was pumped after inspection for maintenance. . c i I Grease Trap (locate on site plan): Depth below grade: feet Material of construction: " ❑ concrete ❑ metal ❑ fiberglass - ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of,scum to top of outlet tee or baffle Distance from bottom of-scum to bottom of outlet tee or baffle , Date of last pumping; date l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts o- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 3 Stone Horse Road Property Address Thomas Grondin Owner Owner's Name information is required for every Osterville Ma 02655 6-23-15 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 per day , Alarm present: El 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 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments. 3 Stone Horse Road Property Address Thomas Grondin Owner Owner's Name information is required for every Osterville Ma 02655 6-23-15 page. City/Town 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 0 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.): At time of inspection d-box appears to be in working order with:no sign of carryover. D-box shows signs of age but no signs of leakage. Pump Chamber(locate on site planj: Pumps in working order: ❑ Yes ❑ No* Alarms in working order: i ❑ 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: l5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts w = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 3 Stone Horse Road Property Address Thomas Grondin Owner Owner's Name information is required for every Osterville Ma 02655 6-23-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 6'x6' ❑ 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.): At time of inspection leaching appears to be in working order with no sign of hydraulic failure. Pit had a water level 2' below invert at time of inspection. Cesspools (cesspool must be pumped as, art of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum.layer Dimensions of cesspool Materials of construction Indication of groundwater inflow , i❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 usetts Commonwealth of Massach W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 3 Stone Horse Road Property Address Thomas Grondin Owner Owner's Name information is required for every Osterville Ma 02655 6-23-15 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.): 7 , Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3113 t Title 5 Official Inspection Foam:Subsurface Sewage Disposal System Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments M ' 3.Stone Horse Road Property Address Thomas.Grondin Owner Owner's Name information is required for every ©steryille Ma 02655 6-23-15 page. Ciiy[fown 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: Z hand-sketch in the area below drawing attached separately A �'� 1�{ Side, of Kouse Z 0 � '23 dl- 13 30 t5ins.-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 3 Stone Horse Road Property Address Thomas Grondin Owner Owner's Name information is required for every Osterville Ma 02655 6-23-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: - ® Check Slope i ® Surface water ® Check cellar. ® Shallow wells Estimated depth to high ground water: No Gw 156" 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: Dec-5-91 -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) R ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Plan on file at BOH i Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 3 Stone Horse Road Property Address Thomas Grondin Owner Owner's Name information is required for every Osterville Ma 02655 6-23-15 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 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 1Tof 17 v Commonwealth of Massachusetts y o� Executive Office of Environmental Affairs ryo9yy� j99 0 Department of F`.1�f � Environmental Protection t Wllllatn F.Weld xe Goverrrar wry Argeo Paul Celluccl David B.Struhs Lt.Gavemor ComrnWsW*r SUBSURFACE SEWAGE DIS POSAL SYSTEM INSPECTIO N FORM PART A - CERTIFICATION Karen Maurer Property Address: 3 Stone,*orse)�x Osterville, 'MA Address of Owner. 10 Bonnievale Dr Date of Inspection: t f, �7 (If different) Bedford, MA 0 01 7 3 0 Name of Inspector W.E. Robinson SR _ Company Name,Address and Telephone Number. ( 5 0 8) 7 7 5-8 7 7 6 W.E. Robinson Septic Service P.O. Box 1089 Centerville MA 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site, sewage disposal systems. The system: l� passes Conditionally Passes _ Needs Further Evaluation By.the Local Approving Authority, _ Fails Inspector's Signature: b I�S "'� Date: of��' The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A,B, C,or D: A] SYS PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. yes,no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not) The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration,.or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a Fonforming septic tank as approved by the Board of Health. t . (revised 11/03/95) 1 One Winter Street a Boston,Massachusetts 02108 a FAX(617)5W1049 0 Telephone(617)292-3S00 40?Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 3 Stone Horse Dr, O•sterville, .. MA Owner. Karen Mal tr:6r Date of Inspection: B]SYSTEM CONDITIONALLY PASSES(continued) _ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed Cl JRTHER 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 the public health,safety and the environment. 1 SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone I of'a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for ooliform 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. 3) OTHER (revised 11/03/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(oontinued) Property Address: 3 Stone Horse Dr, Osterville, MA Owner. Karen Maurer Date of Inspection: 0t D] YSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. _ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a 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 I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. El LAR E SYSTEM FAILS: e following criteria apply to large systems in addition to the criteria above: system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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) The owns or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program r'e4uireme is of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.. (revised 11/03/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST propertyAddmm 3 Stone, Horse Dr, Osterville, MA Owner. Karen Maurer Date of Ingmadon: Check if the following have been done: Is/ information was requested of the owner,occupant,and Board of Health. _L.N/,ne of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates d that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. t plans have been obtained and examined. Note if the are not available with N/A. P y _/The ' or dwelling was inspected for signs of sewage back-up. stem does not receive non-sanitary or industrial waste flow Xe site was inspected for signs of breakout. 4'4Il system components,excluding the Soil Absorption System, have been located on the site. septic tank manholes were uncovered, opened, and the interior of the septic"tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum. The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. VThe facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION property Address: 3 Stone Horse Dr, Osterville, MA Owner. Karen Maurer , Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: ff 3 O gallons Number of bedrooms: a-3 Number of current residents:_ Garbage grinder(yes or no):_Ae_U Laundry connected to system(yea or no):. t'S Seasonal use(yes or,no): 1996 - 3 0 0 0.0gals. Water meter readings,if available: 1 �()S - 21; ., 000 qaI - Last date of occupancy: COMMERCIAI ANDUSTRIAU Type of establishment: Design flow:�gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)— Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING'RECORDS andsource of information; System PUMA as part of inspection:(yes or no)_ If yes,'volume pumped: gallons Reason for pumping: TYPE OF YSTEM Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yea or no) (if yes,attach previous inspection records,if any) Other(explain) APPROXIMATE AGE of all components,date installed(if known)and source of information: "✓r � - Sewage odors detected when arriving at the site: (yes or no) ® (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Prop rty'Address: 3 Stone Horse Dr, Osterville, MA Owner. Karen Maurer Date of Inspection: SEPTIC TANK`� (locate on site plan) ` a Depth below grade: Material of construction:i.4:rete_metal_FR.P—other(explain) t t Dimensions: 7, Sludge depth: 73 Distance from top of sludge to bottom of outlet tee or baffle: d/p n Scum thickness: i—a. Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffie:_ 6L 4 Comments: (recommendation for pumping,condition of inlet and outlet tees or es,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage G E TRAP- (I on site plan). Depth low grade: Mate ' of construction:_concrete metal_FR.p_other(ezplain) Dime no: Scum an: from top of scum to top of outlet tee or baffle: from bottom of scum to bottom of outlet tee or baffle: Comm ts: (reco endation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, eviden of leakage,etc.) (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) PropertyAddebss: 3 Stone Horse Dr, Osterville, MA Owner. Karen Maurer Date of Inspection: TI HT OR HOLDING TANK ( on site plea) Depth ow grade: Ma of constriction:_concrete_metal_FRP_other(explain) Dime - Ins Ca ty: aallona flow: gallons/day level: Co nts: (co tion of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: V (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) PUMP HAMBER_ (locate site plea) Pumps' working order:(yes or no) . Comments: (note condi n of pump chamber,condition of pumps and appurtenances,etc.) (revised 11/03/95) 7 u o SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Add,,, 3 Stone Horse Dr, Osterville, MA Owner. Karen Maurer Date of Inspection: SOIL ABSORPTION SYSTEM(SAS):`.1� (locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: Type: leaching pits,number: leaching chambers,number:_ leaching galleries,number:-- leaching trenches,number,length: leaching fields, number,dimensions: overflow cesspool,number: Comma to: (note confitton of soil,signs of by c failure, level of ponding,condition of vegetatioa,etc.)_1 0 © d �,D( S��GL 4;� C POOLS• (locate n site plan) Number d configuration: Depth-top f liquid to inlet invert: Depth of so' layer. Depth of layer: Dimensions of cesspool: Materials construction: tion: Indication f groundwater: ow(cesspool must be pumped as part of inspection) Commen .(note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation,etc.) PRIVY: (locate on to plan) Mate ' of oonatruction Dimensions: Depth solids: Cc n (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.) (revised 11/03/95) 8 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 3 Stone Horse Dr.; ,Osterville, MA Owner. Karen Maurer Dab of Inspection: t1-I/ SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' 1 W DEPTH TO GROUNDWATER Depth to groundwater: 16: - feet method of determination or approximation: (revised 11/03/95) 9 APPLICATION FOR PERc.OLATION TEST AND OBSERVATION PITS / 'LOC " TION f NO. .. A VIL•LAG DATE APPLICANT UUVOLP13- (zF/li L`PLA FEE ' '• - - ' �� (Non-re undable) • ADDRESS QN10 OC .Yow�2 .(n•dLt, �`� `L$ TBLBPffONB NO. 0' ENGINBER•._TNDYNaS' AiCj (s vv Slob TELEPHONE NO. `c7To2 � DATE SCEIBDULBD ba, 1 (Applicant's Signature) ....................... ..................................:...:..............:......................................................................... ASSESSOR"S tAP 6_ OT NO: SOIL LOU SUB-DIVISION NAME DATE •I� � "� l TIME EXPANSION ARE/As.YES NO �'��}'n OS (nGlfl-�� ENGINEER. TOWN.WATER ✓ PRIVATE WELL Dytvb d- M1UkvU 1 BOARD OF HEALTH EXCA'r A LTOR SKBTgllo-,(Street name, etc., dimensions of lot,.exact location of test holes and percolation tests, locate wetlands In proximity to test holes) I NOTES: - o OLATION RATF" - HOLE NO: '' aELEVATION: TEST HOLE NO: ELEVATION: • 1 1 3 4 4 : 6 rI 6 7' 7 8 5 >v 8 9 9 10 10 . 11 11 12 12 J 13 13 j 14 14 / 15 ' 16 'ABLE FOR SUB-SURFACE SEWAGE: LEACHING FIELD LEA • I1NG PITS / • LEACHING TRENCIIES ITABLE FOR SIJB•-SIJRFACE SEWAGE. REASONS•: : ENOINE911111O PLANS MUST SHOW. VUHBER. ASSIUNEI) ON PERC TEST APPLICATION INAL: COMPLBTED IN ENTIRETY BY P. E. AND RETURNED TO BOARD OF HEALTH ': RETAINED BY APPLICANT T N OF BARNSTABLE LOCATION `.O i— ff ,yl-e � ,�, SEWAGE # -SL� VILLAGE ASSESSOR'S MAP & LOT L 1 r INSTALLER'S NAME & PHONE NO. 'q SEPTIC TANK CAPACITY 1,Otro 3 h LEACHING FACILITY:(type) (size___(,Ou" NO. OF BEDROOMS PRIVATE WELL O PUBLIZWAT�E�R o BUILDER O . OWt�� DATE PERMIT ISSUED: i01-c41 yZ DATE COMPLIANCE ISSUED: I 2- VARIANCE GRANTED: Yes No �/ 0Z 30 No.... .._ FEB.. _ .. _ THE COMMONWEALTH OF MASSACHUSETTS '� AppROVE� QOPartmert BOARD OF HEALTH ' Gorset�atiott � a, 9 attestable �.. ................. .OF............ f?- -....._-.._..-...._... ppliratiun for Piupuuttl Workii Tonutrurtiun f amit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at: ..............••---.......... _.....�-:'_".....`.. S_.._..........r:�N.E�......=sue- . :? ........ --Location-Address or Lot No. lliOO O Addressa.di' u .Q►!L1......... ................. ns a er '( tt/Ve � Address Type of Building 3 Size Lot__��.,.�� ....._Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) a'4 Other—T e of Building No, of persons......................... Showers YP g ---------------••-•--------• P --- ( ) — Cafeteria ( ) 04 Other fixtures ........................j-............................................................................................................................ W Design Flow.............IX�......................gallons per person per day. Total daily flow.............3 .. _.__.....____.__gallons. WSeptic Tank—Liquid capacity_)°;�4P.gallons Length__. „. Width:.y'...19.._ Diameter________________ Depth__. x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area---- ..sq. ft. 3 Seepage Pit No..................... Diameter.......I o.'__.___ Depth below inlet......R I......... Total leaching area__?(__.. ....sq. ft. Z Other Distribution box ("L-) Dosing tank ( ) y �t.�.tea.S CssP� > . -t z- 1 � Percolation Test Results Performed b ....�M........................�.........,_......_...�� Date__........................`�. ,.a Test Pit No. 1.._L__Z-minutes per inch Depth of Test Pit....... Depth to ground water........!!'' ..__. flit Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 --••-••...•••-•----••-----•-..._••••. •••--•••--••-•.........................•--....._........._.......... ........----...............____---_..._. 0 Description of Soil.........�•--3�•_••••_.....TF, e S.�r� j...__.30..................................�5 � t _- r x UW ---••••••--•-------••---• .-•-----....-••••••---••-••-•-••-•--•------•---••-----•----••---•••--••-••-....---•••--•---•--•--•-•=•................•-._...._....•-•-•--•••-•••••-••........................ 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 AITL U - 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has ben issued by the board of health. Signed .. Mt�?:L+ ��.Q�---n' e Application Approved By. -��:... .__..... .. ��c Date Application Disapproved for the following reasons___________________________________ __________________________________________________ ..........»» .............................••--•--------••-•---............._...---•----..................-------......._..:..----............_..--•-••--•--•---.._....-------..._...:.-........................_....» Date Permit No.....Z.12� .V l Issued.---....:1 Date .................. FRis......................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH- �g f/5 ........................ ....... .. ....................OF.................................... . ppliration for BiBpooul Iforkii Towitnution Prrutit Application is hereby made for a Permit to Construct QV—) or Repair aii—Individual Sewage Disposal System at: .......;T _-i�....... .......... L c.-r 4 S 4 .................... ....................................................................... Location-Address or Lot NO. I L..... ............. ........... ......... 14 '0—1'Ah I ................................Address .................................... ....... To wer n4c .............. ............ ... ..t) _aj�........1_k44 tiill.............................................................................................. or.......... r 1Lnsf'a1t-_r 1(e , M-P, Address Type of Building Size Lot..Al.,..c.t=4......Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder Other—Type of Building ............................ No. of persons..........................-- Showers Cafeteria Other fixtures ............................................ ----------------------------------------­--------*...... Design Flow............. ......................gallons per person per day. Total daily flow............... ..................gallons. 1 1:14 Septic Tank—Liquid capacity_lcz?�2gallons Length..- Width;A'..j_5-.". Diameter................ Depth......S.........., Disposal Trench—No. .................... Width..................... Total Length.................... Total leaching area....2-'�_ .....sq. ft. Depth below inlet...... .......... Total leaching area_2.�T-. Seepage Pit No.......'...,-...... Diameter.......1.�2........ J....sq. ft. Z Other Distribution box Dosing tank Percolation Test Results Performed )Date........... 7......L.......... ........................... Test Pit No. I....4­3'.minutes per inch Depth of Test Pit....... Depth to ground water........!".. `..--. '44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 ..................................................................................................................o.......................................... 0 Description of Soil......-- .. . . W r•......................i--------------- ........... ............. ................................ U ................................................................................................................................................................................o........................ .......................... .........'..V...............................................................7=..............................................................................7---­---­------ U Nature of Repairs or Alterations—Answer when applicable..........................................................................w.................... ............................................... ........................................................................................................ ........................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T I T LZZ 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 the board of health. Signed........ .................... ................. ............ D t Application Approved By........ ....... ............ ....................................... Date Application Disapproved for the following reasons:............................................................................................................ ...................................................................................................................................................................................................... Date Permit No.....Z�....................................... Issued......... 1­77-2': �....... Date — -------------- --------- ----------------------------- --------- ----------------------- --------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...............OF......... ..................... .......... .....I..................... .............. Tinfifiratr of Toutplitturr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired by......L.3.C.K�. ............ ....................................................................................................................................... L . — Installer at....L.0 .... A Z7 /J....... . ......V ............ ................................................................ has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No..-(/', �� —.I"—........ dated-_...- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.................k... ....... Inspector..-............... ..................................... -----------------------------I--------------------------------------------------------- ---------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH . .................I............ N ,. .......... ................ Disposal Worko Tonstrudion ramit Permission is hereby granted------- .........�qbAS.r........................................................................................ to Construct or Repair an Individual Sewage Disposal System at No....:..... H_/D AJ Lf' L4 S_ -19 ....................................................................Rd-,-------------------------------------------------------------------------- Street as shown on the application for Disposal Works Construction Per N 95......V'... ..................................------------------------------------------------------------------- Board of Health DATE.-- ................... 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SIL.DOM ' 01 lu -- -A •' --- ------ , x ,0 1/rp e•,o D/r 9-ua(r 2-IN wir n I• ' --- -------------� _ .•.- --------- , y._y s/1•a 9'-,07/r ~GU-aB0 PAl1D OR ` �1 • © K 1 I 1 I(EYVI .An InAle•1•d _ I L -0.0. a.•__ 1 WN 1 0 Gm•M - DO 10 Int�1o. • - _-• .. � ' ' ' 70 ACCEPT SIFP FTG.(IYP.) dl T9-.r POURED.CMC.FWNOATIM WALL 1 I 1 t I •W DE0.. ON 9••t5-CANC.FOOTING IY-r O Plan FOUNDATION NOTES: STRO W a y DAYS z }=J N A A Foundation SCALE,/1•-1'-r IO BE OF x50O PS: �•3 DAYS IJ POURED CM(RETE MRu"SANG BASE aj j WHCRETE TO 9E PROlEC1FD FROM FREEZING .. MADE ALL POURED i:ODTNGS TO DE M BAN MALL XPEIOYEIV 9'r D.C. ASPHALT TM DAyPPROOF'fOUNDAIION MIALL _ . PLACE,/x•A 12•GALY.ANCNM 9O1T5 OU DESIGN CRITERIA SPECIFICATIONS DESIGN FLOW ALL SYSTEM COMPONENTS (310 CMR 15.221) 1. BUILDING USE: SINGLE FAMILY DWELLING 1. ALL SYSTEM COMPONENTS SHALL BE MARKED WITH MAGNETIC TAPE OR A 2. NO. OF BEDROOMS: 3 COMPARABLE MEANS IN ORDER TO LOCATE ONCE BURIED. 3. DESIGN FLOW: 110 GPD PER BEDROOM PIPE (310 CMR 15.221) 4. TOTAL DAILY FLOW: 330 GALLONS 1. BUILDING SEWER: 4-INCH DIA. SCH 40 PVC 5. GARBAGE GRINDER: NO 2. SEPTIC TANK TO DISTRIBUTION BOX: 4-INCH DIA. SCH 40 PVC OR SDR35 PVC, MIN. SLOPE 1/8 IN. PER FT. 8'-6" 2'-10" 3. DISTRIBUTION LINES: 4-INCH DIA. SCH 40 PVC OR SDR35 PVC. SOIL ABSORPTION AREA 4. DISTRIBUTION LINES FIRST 2 FEET DOWNSTREAM OF DISTRIBUTION BOX: SOLID WALL -2'-0"- 4-INCH DIA. SCH 40 PVC OR SDR35 PVC, LAID LEVEL. (1)021"CONCRETE COVER 1. DESIGN PERCOLATION RATE: 2 MIN. PER INCH DISTRIBUTION BOX (310 CMR 15.232) 2. SOIL TEXTURAL CLASS: 1 1. DISTRIBUTION BOX RATED FOR H-10 LOADING 3. LONG TERM ACCEPTANCE RATE: 0.74 GPD/SF 2. DISTRIBUTION BOX SHALL HAVE A MINIMUM INSIDE DIMENSION OF 12 INCHES AND A 4. EFFECTIVE AREA REQUIRED: 330 GPD/ 0.74 GPD/SF = 446 SF MINIMUM SUMP DEPTH OF 6 INCHES BELOW OUTLET INVERT. SEAL BOX WATERTIGHT WITH ® O OO 4" MIN. TOPSOIL. SUPPLEMENT 5. EFFECTIVE AREA PROVIDED = 33.5 X 12.83 = 429.8 SF (BOTTOM AREA) + NON-SHRINK GROUT. - EXISTING AS REQUIRED (33.5 X 2 X 2) + (12.83 X 2 X 2) = 185.32 (SIDEWALL AREA+ = 615.52 (TOTAL) 3. DISTRIBUTION BOXES BURIED GREATER THAN 9-INCHES SHALL BE EQUIPPED WITH 0 O 0 6. MIN. SEPARATION, BOTTOM STONE TO ESHGW: REQ'D: 5 FT; PROVIDED: 5 FT WATERTIGHT RISERS TO WITHIN 6-INCHES OF FINISH GRADE. 4'-10" - O 0 © 2" PEASTONE SELECT SOIL FILL (310 CMR 15.255(3)) ® O © FILTER FABRIC OVER TOP AND AT SIDES OF SELECT SOIL 1. SELECT SOIL FILL MATERIAL FOR SYSTEM CONSTRUCTION SHALL CONSIST OF 12" MIN. FILL. OVERLAP ADJACENT SECTIONS 12" MINIMUM IMPORTED SOIL. ® © M SUITABLE 2. SELECT SOIL FILL MATERIAL: COMPRISED OF CLEAN, GRANULAR SAND, FREE FROM 0'-6 1/4" A MATTERERIAL IAL ORGANIC MATTER AND DELETERIOUS SUBSTANCES. MAXIMUM PARTICLE SIZE: 2 INCHES. GENERAL NOTES 3. PERFORM A SIEVE ANALYSIS ON A REPRESENTATIVE SAMPLE OF THE FILL. UP TO -_- -_ - - - - - _- - - --- --- - - - - - - Legend 45% BY WEIGHT OF THE FILL SAMPLE MAY BE RETAINED ON A #4 SIEVE. ALSO PERFORM 0'-4 3/4" g 1. SEPTIC SYSTEM CAPACITY DOES NOT INCLUDE A GARBAGE GRINDER. A SIEVE ANALYSIS ON THE FRACTION OF THE FILL SAMPLE PASSING THE #4 SIEVE. (2)LIFTING HOOKS 5"KNOCKOUTS 2. CONSTRUCTION IS TO CONFORM WITH THE REQUIREMENTS OF THE STATE SANITARY SUCH ANALYSIS SHALL DEMONSTRATE THAT THE MATERIAL PASSING THE #4 SIEVE MEETS (1)CENTERED \ \\ \\ \\ \\ \\ \\ \\ \\ \\ \\ \\ \\ \\ \\ \\ \\ CODE, TITLE 5, AND LOCAL REGULATIONS. THE FOLLOWING GRADATION: EACH SIDE 3. THE SEPTIC SYSTEM OWNER SHALL AT A MINIMUM HAVE THE SEPTIC TANK „ \� ( ) SIEVE EFFECTIVE PARTICLE SIZE PERCENT PASSING 0-4 INSPECTED YEARLY AND THE SEPTIC TANK PUMPED EVERY 2 YEARS TO INSURE 0'-6" PROPER PERFORMANCE. #4 4.75 mm 100 (3)ROWS 4. HEAVY EQUIPMENT SHALL NOT BE PERMITTED TO CROSS THE LEACHING AREA. #50 0.30 mm 10 TO 100 /\ 5. THE CONTRACTOR SHALL VERIFY ALL EXISTING UTILITY LOCATIONS PRIOR TO \ AGGREGATE\ ® ®® ® AGGREGATE #100 0.15 mm 0 TO 20 ®®" \/ ® 0 0 ® ® \ CONSTRUCTION COMMENCEMENT BY CONTACTING DIGSAFE AT 1-888-344-7233. #200 0.075 mm 0 TO 5 0 0 0 0 0 0 0 0 0 2'-10 6. EXCAVATION AND FLAGGING OF THE SOIL ABSORPTION SYSTEM SHALL CONFORM TO LEACHING CHAMBER INSTALLATION 2'-0" C:) O O O C:) O O O O O O 310 CMR 15.246 (1 & 2). 1. EXCAVATE AND LEVEL INSTALLATION AREAS. O O O O O O O O O O O 0'-3 1/2" 7. NO FIELD MODIFICATIONS OF THE SYSTEM SHALL BE MADE WITHOUT PRIOR WRITTEN 2. SMOOTH IRREGULARITIES IN THE EXCAVATION. A LEVEL, FLAT SURFACE IS REQUIRED. 0'-5 3/4 APPROVAL OF THE DESIGN ENGINEER AND THE BOARD OF HEALTH. 8. CONSERVATION APPROVAL IS NOT REQUIRED PER 310 CMR 10.00. 3. INSTALL LEACHING CHAMBERS (ACME-SHOREY ITEM #LC5) 0 2 9. CONSTRUCTION DETAILS: 4. INSTALL 4" PIPE TO EACH LEACHING CHAMBER QFTAII , A. ALL PIPES, BEDS, SEPTIC TANK, D. BOX TO BE LAID ON FIRM BASE. DO 5. FILL PERIMETER TO TOP OF CHAMBERS WITH SELECT SOIL FILL MATERIAL. LEACHING CHAMBER NOT INSTALL SYSTEM ON FROZEN GROUND OR LEAVE SYSTEM UNCOVERED FOR 6. COVER LEACHING CHAMBERS WITH A MINIMUM OF 12" OF GRANULAR COVER AFTER 0'3" EXTENDED PERIODS OF TIME. CONSOLIDATION FOR H-10 APPLICATIONS. NO STONES OVER 3" OR DEBRIS SHALL BE B. ALL FINISH GRADES AND DISTURBED AREA TO BE LOAMED & SEEDED. USED IN COVER MATERIAL. 10. FILTER FABRIC: MIRAFI 14ONC OR APPROVED EQUAL. LEACHING CHAMBERS LEACHING CHAMBER INSTALLATION 11. SYSTEM MUST BE INSPECTED BY THE BOARD OF HEALTH OR ITS AGENT & AN NOT TO SCALE NOT TO SCALE ASBUILT PLAN AND CERTIFICATION IS REQUIRED BY DESIGN ENGINEER PRIOR TO BACKFILLING OR CONCEALING SYSTEM COMPONENTS. 12. NO PERMANENT STRUCTURES ARE TO BE CONSTRUCTED OVER ANY PART OF THE SEPTIC SYSTEM. 13. ELEVATIONS REFER TO AN NAVD '88 DATUM 14. EXISTING CONDITIONS INFORMATION BASED ON AN EXISTING CONDITIONS PLAN BY CAPESURV DATED JULY 28, 2020, 15. ALL SEWAGE DISPOSAL SYSTEM COMPONENTS ARE GREATER THAN 400 FEET FROM SURFACE WATER RESERVOIRS AND GREATER THAN 200 FEET FROM TRIBUTARIES TO SURFACE WATER RESERVOIRS. 16. THERE ARE NO KNOWN EXISTING WELLS WITHIN 150 FEET OF PROPOSED SOIL ABSORPTION AREA, OR WITHIN 50 FEET OF PROPOSED SEPTIC TANK. 17. WATER SERVICE VIA MUNICIPAL WATER SERVICE. SOIL EVALUATION SUMMARY SOIL EVALUATOR: FRANK HOLMES, P.E., (SE #1081) SOIL EVALUATOR APPROVED IN: 1996 WITNESSED °Y: BARNSTABLE B.O.H. - DAVID STANTON EVALUATION PERFORMED: 9/24/2020 jj// ��,,�, jq� ,t p l,��a a f FINISH GRADE L i x < Hi NOTE: IF BURIED GREATER THAN 9" 7 BELOW GRADE, A RISER TO WITHIN 6" o, COVER MUST BE WATERTIGHT, 1'•r ao :.'' :;w TEST PIT 1 (WEST) TEST PIT 1 (EAST) OF FINISH GRADE MUST BE PROVIDED. AND RATED FOR H-20 LOADING :r.w • �1i"' 4 EXISTING GRADE = 23.Of EXISTING GRADE = 25.5f d PRECAST CONCRETE •. ,. r"r rd� lo;,'. ._: 2" MIN. SOIL SOIL SOIL COLOR SOIL SOIL SOIL SOIL COLOR SOIL CONSTRUCTION _�; �:'�°a--; `''� �, '' '`•' I HORIZON TEXTURE (MUNSELL) MOTTLING HORIZON TEXTURE (MUNSELL) MOTTLING OUTLET MUST BE LEVEL , M1�i ,e -on R TWO F a • " . __.: Q 0 4" PVC FROM FOR FEET MIN. NONE A SL 1OYR 3 2 NONE SEPTIC TANK f 2 A SL 10YR 3/2 2 / East BUSY 6" B SL 1 OYR 4/6 NONE 611 B SL 1 CYR 4/6 NONE (+ •..,a � _ NOTE 1 2" MIN. a _ LEVEL BASE b 6" DEPTH 1.5" MINUS �\/�\/�\'-UNDISTURBED NATURAL CRUSHED STONE \�j SOIL OR SUBGRADE C SAND 7.5YR 4/3 NONE C SAND 7.5YR 4/3 NONE / COx MUM ED DRYOD95% (MODIFIED PROCTOR) NOTES: PER ASTM D1557. [1] PROVIDE MIN. 1" DROP BETWEEN BOTTOM OF INLET TEE AND OUTLET INVERT. 6-OUTLET DISTRIBUTION BOX 310 CMR 15.232 132" 132, TYPICAL CROSS SECTION SCALE 1"=1' PERC RATE CONDUCTED ON LDT N84'42120"E 1991-1 1 -12, < 2MP1 50.00' .1 ABANDON EXISTING SEEPAGE PITS EXISTING 1,000 GALLON SEPTIC TANK Revision By Appd. YY.Il I PmOPC E;D EXISTING SEWER SERVICE • I I Board of Health Review FH 20.1 1.1 E Issued By Appd. YY.Mkkl Qn INSTALL DISTRIBUTION BOX01) o o v; ni Dwn. Chkd. Dsgn. YY.MM.D[ _ Permit-Seal R Di 00' CHAMBERS INVERT INTOEL. 20.50 �N OF Mgssgc� 00 •� �% Z Q) FRANK GJ'rn TEST PIT 1 cb ^ EXISTING DWELLING PRECAST �-S HOLMES TOF EL. 32.5 +/- NOTE: SEE PLAN VIEW FOR EXISTING AND DISTRIBUTION BOX ,� CIV IL O �j FINISH GRADES. SEE DETAILS FOR No.FINISH 203 PLACE 40 l IMPERVIOUS BARRIER N ---- COMPONENT SPECIFICATIONS INV. IN EL. 20.97 FINISHED GRADE VARIES - ELEV. 22.50 - 22.80 \ 5' FROM EDGE OF AGGREGATE INV. OUT EL. 20.80 2% MIN. SLOPE OVER LEACHING BED pp� CrSTE TOP OF BARRIER ELEV. 20.50' EXISTING SEWER FSS/ONALti� SERVICE BOTTOM OR BARRIER ELEV. 16.50 EXISTING 1,000 2 4', SCHED. 40PVC ® 4% INSTALLATION TO BE SUPERVISED BY GALLON ENGINEER THREE ACME-SHOREY LEACHING - SEPTIC TANK ClienVProject CHAMBERS INV. EL. 21.30 AGGREGATE (310 CMR 15.247) ,2�, INV. 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