HomeMy WebLinkAbout0088 AMELIA WAY - Health 88 Amelia Way
Marstons Mills F/R
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TROY WILLIAMS
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SEPTIC INSPECTIONS 8, viol
Certified by MA Department of Environmental Protection 6661 (508) 385-1300
19 Hummel Drive pgM
South Dennis, MA 02660 rr
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_ - COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500
TRUDY CORE
Secretary
ARGEO PAUL CELLUCCI DAVID B. STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
Q 1 CERTIFICATION
Property Address: v 8 A m Q I I*O. WcK Name of Owner Do llI a U S k%;}'I_
1
/A o r s+o vt's NI 111 S Address of Owner: as 4 n 4_1 1 c.
Date of Inspection: 6 /a 3 /9 9 M
Name of Inspector:(Please Print) Troy Williams O
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)
Company Name: Trot/ Williams Srt. .ic Inspections
Mailing Address: tg Hummel Drive, So. Dennis, MA 02660
Telephone Number: (508) 385-1300
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:
Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
_ Fails c /
Inspector s Signature: �1, b Date: 1a3/q 9'
The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty (30) days of
completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner
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.
NOTES AND COMMENTS
Although system meets the minimum requirements set forth by the Massachusetts Department of
Environmental Protection,certification is not to be construed as a guarantee of future working condition
of system,piping or components. This inspection represents the conditions of the system on the Date of
Inspection noted above.
revised 9/2/98
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (ccrrfi x )
Property Address:
owner: 88 Amelia Way,Marstons Mills,MA
Date of Inspection: Donald E. Smith
June 23, 1999
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure
criteria not evaluated are indicated below.
COMMENTS:
B. SYSTEM CONDITIONALLY PASSES: IV14
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.
Indicate 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, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance(attached)indicating that the tank was installed within twenty(20) years prior to the date of the inspection; or
the septic tank, whether or not metal, is 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 complying septic tank as
approved by the Board of Health.
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
i
revised 9/2/98 ,.agc2o, ,,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 88 Amelia Way,Marstons Mills, MA
Owner: Donald E. Smith
Date of Inspection: June 23, 1999 �1 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: A//4
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 IN ACCORDANCE WITH 310 CMR 15.303(1)(b)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 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
Private water supply well,unless a well water analysis 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. Method used to determine distance (approximation not valid).
3) OTHER
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
88 Amelia Way,Marstons Mills,MA
Property Address: Donald E. Smith
Owner: June 23, 1999
Date of Inspection:
D. SYSTEM FAILS: N119
You must indicate either 'Yes" or "No" to each of the following:
I have determined that one or more of the following failure conditions exist as described 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.
Yes No
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.
E. LARGE SYSTEM FAILS: A///9
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:
The 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:
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 II of a public
water supply well)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further information.
revised 9/2/98 F,u�r 4of II
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 88 Amelia Way,Marston Mills,MA
Owner: Donald E. Smith
Date of k-pecti_. June 23, 1999
Check if the following have been done: You must indicate either 'Yes' or 'No- as to each of the following:
Yery No
�/ _ Pumping information was provided by the owner, occupant, or Board of Health.
2+ _. None of the system components have been pumped-for-at least two weeks and-the system has been receiving normal flow
rates during that peruod. Large volumes of water have not been introduced into the system recently or as part of this
/ inspection.
v _ As built plans have been obtained and examined. Note if they are not available with N/A.
V _ The facility or dwelling was inspected for signs of sewage back-up.
_ The system does not receive non-sanitary or industrial waste flow.
_ The site was inspected for signs of breakout.
Y _ All system components, excluding the Soil Absorption System, have been located on the site.
The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles
or tees, material of construction, dimensions,depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
_ Existing information. For example, Plan at B.O.H.
JG _ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)
/ 115.302(3)(b)I
V - _ The facility owner (and occupants,if different from owner) were.provided with information on tha.propermaintanance of
Subsurface Disposal Systems.
revised 9/2 1
Page 5 of I I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
Owner: 88 Amelia Way,Marston Mills,MA
Date of Inspection: Donald E. Smith
June 23, 1999
RESIDENTIAL: FLOW CONDITIONS
Design flow: //U g•p•d./bedroom.
Number of bedrooms (design): Number of bedrooms(actual):3
Total DESIGN flow3
Number of current residents:
Garbage grinder(yes or no): /Vo
Laundry(separate system) (yes or no):/VG; If yes, separate inspection required
Laundry system inspected (yes or no)
Seasonal use(yes or no):�/0.
Water meter readings,if available(last two year's usage(gpd): yHo-✓A, /wWe-
Sump Pump(yes or no): A/o
Last date of occupancy:-01.,--
COMMERCIALfINDUSTRIAL: A114
Type of establishment:
Design flow:_ gpd ( Based on 15.203)
Basis of design flow
Grease trap present:(yes or not_
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 and source of information:
o
System pumped as part of inspection: (yes or no) A10 o v.�✓.
If yes, volume pumped: gallons
Reason for pumping:
TY E F SYSTEM
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) (if yes, attach previous inspection records,if any)
I/A Technology etc.Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXJMATE AGE of all components, date installed(if known) and source of information: vrs I J 1 2
��r ems- burl. cf .. 7/ Z
Sewage odors detected when arriving at the site: (yes or no)LVQ
i'ev i sed 9/2/98 rd�, eor
SUBSURFACE SEWAGE DISPOSAL SYSTEIA INSPECTION FORM
PART C
SYSTEM INFORMATION(corr6mhed)
Property Address:
Owner: 88 Amelia Way,Marstons Mills,MA
Date of Inspection: Donald E. Smith
BUILDING SEWER: June 23, 1999
(Locate on site plan)
Depth below grade: $p
Material of construction:_cast iron_3/40 PVC_other(explain)
Distance from private water supply well or suction line IV49
Diameter "
Comments: (condition of joints, ve�nntting, evidence of leakage,etc.)
cI ✓ F Ae- o �' as�Qc riot,
SEPTIC TANK:
(locate on site plan)
Depth below grade:_
Material of construction:J16oncrete_metal_Fiberglass _Polyethylene_other(explain)
If tank is metal,list age_ hs.age confirmed by Certificate of Compliance_(Yes/No)
Dimensions: 5 / /d 00 "//0.1
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: '
Distance from top of scum to top of outlet tee or baffle: �r
Distance from bottom of scum to bottom of outlet tee or baffle: 8�
How dimensions were determined: Pra ba_
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structuraHntegrity,
evidence of leakage,etc.) f UL +e-e-J' wo,.e N
,.�
J' �, r. o r 1C�1..a n rd .✓ o
Al GEC.o H.. N., h -�Of - I.. S U✓t O✓fl ni✓ / fi )i r.1,q o r cA ✓ U i0fLt /C
GREASE TRAP: /V
(locate on site plan)
Depth below grade:_
Material of construction:_concrete_metal_Fiberglass _Polyethylene_other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.)
revised 9/2/98 Nge7ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner: 88 Amelia Way,Marstons Mills,MA
Dace of Inspection: Donald E. Smith
June 23, 1999
TIGHT OR HOLDING TANK:N/19 (Tank must be pumped prior to, or at time of, inspection)
(locate on site plan)
Depth below grade:_
Materiel of construction:_concrete_metal_Fiberglass_Polyethylene_other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm present
Alarm level: Alarm in working order:Yes No
Date of previous pumping:
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert: ": ' 1
Comments:
(note.if level and distribution is equal,evidence_of solids carryover, evidence of leakage into or out of box, etc.)
ti t.J J y k d lrl�c✓
PUMP CHAMBER: AIM
(locate on site plan)
Pumps in working order:(Yes or No)
Alarms in working order(Yes or No)
Comments:
(note condition of pump chamber,condition of pumps and appurtenances, etc.)
revised 9/2/98 P.gesofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner: 88 Amelia Way,Marstons Mills, MA
Date of Inspection: Donald E. Smith
June 23, 1999
SOIL ABSORPTION SYSTEM(SAS):
(locate on site plan, if possible; excavation not required, location may be approximated by non-intrusive methods)
If not located,explain:
Type: L,
leaching pits, number: G"e-
leaching chambers,number:_
leaching galleries,number:_
leaching trenches,number, length:
leaching fields,number, dimensions:
overflow cesspool,number:
Alternative system:
Name of Technology:
Comments:
(note condition of soil,�signs of hydraulics failure, level of ponding, damp soil, condition of vegetation, etc.)
riJ r�'f� ka CA TU h i C.`h aA ae Cf ti P/
fo it
( G✓
��„ -C t✓ vt � O 7
r <r L Gam. 7 GJ t L p/iL 3 G v1 f CESSPOOLS:�( A
(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(cesspool must be pumped as part of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:—Z//l7
(locate on site plan)
Materials of construction:
Depth of solids: Dimensions:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
revised 9/2/98 P.age9ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner: 88 Amelia Way,Marston Mills,MA
Date of Inspection: Donald E. Smith
June 23, 1999
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
13w� k. c -e, 9 e .
1.
Dif �-
I
/ouo ya��dh
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t ,
u-13ox
wi "I 3r 'S �'L
revised 9/2/98
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continue
Property Address:
Owner: 88 Amelia Way,Marston Mills,MA
Date of Inspection: Donald E. Smith
June 23, 1999
NRCS Report name (�
Soil Type_
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate
Deep
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to Groundwater 15+ Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
/ Observed Site iAbutting property, observation hole, basement sump etc.)
✓ Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
Checked pumping records
Checked local excavators, installers
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
I 4 G S N� J &k U h /t" f/q S ,a V,/ -
hp o�
revised 9/2/98
r
FAILED
COMMONWEALTH OF MASSACHUSETTS
z
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
a c DEPARTMENT OF ENVIRONMENTAL PROTECTION
�4 FAILED INSPECTION
14-9
350 MAIN STREET AP
r WEST YARMOUTH,MA..
508-775-2800
Y �+
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
MAP-49 PARC-004 --�
Property Address: 88 AMELIA WAY
MARSTONS MILLS,MA 02648 CD
Owner's Name: DIANA,GINA L. - .---q c
t
Owner's Address: 88 AMELIA WAY < 4.�
MARSTONS MILLS,MA 026487 ' w
Date of Inspection SEPTEMBER 15,2004 CD
Name of Inspector:(please print) JAMES D. SEARS 4 .j
Company Name: A&B Canco
C-111
Mailing Address: 350 Main Street t rn
West Yarmouth,MA 02673
Telephone Number: 508-775-2800
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
Jaining and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
�pproved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
�J
4) Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: Fl-O�-� 11"V
The system inspector shall s it 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 a--id 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 tot he buyer,if applicable,and the approving authority.
Notes and Comments
****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.
Title 5 Inspection Form 6/15/2000 1
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 88 AMELIA WAY
MARSTONS MILLS,MA 02648
Owner: DIANA,GINA L.
Date of Inspection: SEPTEMBER 15,2004
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes: N/A
I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes: N/A
_ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.
The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"
please explain.
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 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 Tess than 20 years old is available.
ND explain:
_ 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
obstruction is removed
distribution box is leveled or replaced
ND explain:
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 removed
ND explain:
Title 5 Inspection Form 6/15/2000 2
Page 3 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 88 AMELIA WAY
MARSTONS MILLS,MA 02648
Owner: DIANA,GINA L.
Date of Inspection: SEPTEMBER 15,2004
C. Further Evaluation is Required by the Board of Health:N/A
_ 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 CAM 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 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 septic tank and SAS and the SAS is within a Zone 1 of 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 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:
Title 5 Inspection Form 6/15/2000 3
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 88 AMELIA WAY
MARSTONS MILLS,MA 02648
Owner: DIANA, GINA L.
Date of Inspection: SEPTEMBER 15,2004
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
J 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
J Liquid depth in pit is less than 6"below invert or available volume is less than%2 day flow
J 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 SAS,cesspool or privy is below high ground water elevation
N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a
surface water supply
N/A Any portion of a cesspool or privy is within a Zone 1 of a public well
N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well
N/A 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 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 or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.)
YES (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: N/A
To be considered a large system the system must service 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
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 II of a public water supply well.
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system is 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.
Title 5 Inspection Form 6/15/2000 4
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 88 AMELIA WAY
MARSTONS MILLS,MA 02648
Owner: DIANA,GINA L.
Date of Inspection: SEPTEMBER 15,2004
Check if the following have been done. You must indicate"yes"or"no"as to each of the following
Yes No
J 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?
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?
J Was the site inspected for signs of break out?
J 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)has been determined based on:
Yes No
Existing information. For example,a plan at the Board of Health.
J Deternimed 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(3Xb)]
Tide 5 Inspection Form 6/15/2000 5
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 88 AMELIA WAY
MARSTONS MILLS,MA 02648
Owner: DIANA, GINA L.
Date of Inspection: SEPTEMBER 15,2004
FLOW CONDITIONS
RESIDENTIAL -,/
Number of Bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CUR 15.203(for example: 110 gpd x#of bedrooms: 330
Number of current residents: 2
Does residence have a garbage grinder(yes or no): NO -
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no): YES
Seasonal use(yes or no): NO
Water meter readings,if available(last 2 years usage(gpd)):
Sump pump(yes or no) 110
Last date of occupancy: PRESENT
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203):
Basis of design flow(seaNs/persons/sgft,etc.):
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/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: JULY-2004
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: gallons—How was quantity pumped determined?
Reason for pumping:
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)
Tight tank Attach copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
1996 PERMIT 95442
Were sewage odors detected when arriving at the site(yes or no): NO
Title 5 Inspection Form 6/15/2000 6
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 88 AMELIA WAY
MARSTONS MILLS,MA 02648
Owner: DIANA,GINA L.
Date of Inspection: SEPTEMBER 15,2004
BUILDING SEWER(locate on site plan): J
Depth below grade: 10"
Materials of construction: Cast iron J 40 PVC other(explain)
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK(locate onsite plan):
Depth below grade: 16"
Material of construction: ✓ concrete metal fiberglass polyethylene
_ other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1000-GALLON PRE CAST
Sludge depth: 2"
Distance from top of sludge to the bottom of outlet tee or baffle: 28"
Scum thickness: 2"
Distance from top of scum to top of outlet tee or baffle: 12"
Distance from bottom of scum to bottom of outlet tee or baffle: 16"
How were dimensions determined: AS BUILT&TAPE
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as
related to outlet invert,evidence of leakage,etc.):
MAIN TANK AT WORFING LEVEL,TANK&COVERS 16"BELOW GRADE.
GREASE TRAP(loca`ed on site plan) N/A
Depth below grade:
Material of construction: concrete metal fiberglass _ polyethylene other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as
related to outlet invert,evidence of leakage,etc.):
Title 5 Inspection Forma 6/15/2000 7
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 88 AMELIA WAY
MARSTONS MILLS,MA 02648
Owner: DIANA, GINA L.
Date of Inspection: SEPTEMBER 15,2004
TIGHT or HOLDING TANK: N/A (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/day
Alarm present(yes or no)
Alarm level: Alarm in working order(yes or no):
Date of last pumping
Comments(condition of alarm and float switches,etc.):
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.,):
D BOX IS 16"X 16"—22"BELOW GRADE,ONE LINE IN,ON LINE OUT.
BOX IS SOLID.
PUMP CHAMBER: N/A (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
Tide 5 Inspection Form 6/15/2000 8
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 88 AMELIA WAY
MARSTONS MILLS,MA 02648
Owner: DIANA, GINA L.
Date of Inspection: SEPTEMBER 15,2004
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number: 1
leaching chambers,number:
leaching galleries,number
leaching trenches,number,length
leaching fields,number, dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of
vegetation,etc.)
LEACHING IS ONE 1000-GALLON PRE CAST PIT 22"TO COVER.PIT IS FULL UP TO INLET LINE.
NOT WORKING,NEED TO REPLACE LEACHING.
CESSPOOLS: N/A (cesspool must be pumped as part of inspectionXIocate 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(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation etc.):
PRIVY: N/A (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.)
Title 5 Inspection Form 6/15/2000 9
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 88 AMELIA WAY
MARSTONS MILLS,MA 02648
Owner: DIANA, GINA L.
Date of Inspection: SEPTEMBER 15,2004
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at leash two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
I
q`
33r-� /
CI
� 3.
1
Title 5 Inspection Form 6/15 2000 10
Page I 1 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 88 AMELIA WAY
MARSTONS MILLS,MA 02648
Owner: DIANA, GINA L.
Date of Inspection: SEPTEMBER 15.2004
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to no groundwater 12 feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observation site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
HAND DUG TEST HOLE 12' NO WATER.
TEST HOLE 3' BELOW BOTTOM OF PIT.
�3a7T,N
P�T
�U u Lt,•�-�trc--
Title "
� Inspection Form 6/1 z/_2
000 11
TOWN OF BARNSTABLE
LOCATION X",6 lt44 1W/14 V SEWAGE # ?00 Y-67?
VILLAGE �i,�rS�ohS `Lli`�� ASSESSOR'S MAP & LOT lY9- 0.51
INSTALLER'S NAME&PHONE NO. 308- 5'20- F7 �f /,3w,1
SEPTIC TANK CAPACITY /DDa
T-tiACH NG FACII.ITY: (type) 2-,5-0 dry a,/r-Al (size)
NO.OF BEDROOMS
BUILDER OR OWNER gldd)a
PERMITDATE: l0 - l 2- 0 Y COMPLIANCE DATE: 10
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 of leaching facility) Feet
Furnished by
i
014 C
0
0
No. 5 3 J Fee U�—
4. THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: �✓
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
Zfppliration for �Dizpoal bpgtem Conztrurtion Permit
Application for a Permit to Construct( . )Repair(degrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No.
Assessor's Map/Parcel
Installer's NgLme,Address,and Tel.No.po-e/2D—%736 Designer's Name,Address and Te.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applica le) 1reS *11 J-ffm 2 -jS"- o Z ✓,i•t/
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this B and of Jiealth
Signed pp rr Date
Application Approved by Date l y 1.1-0 y
Application Disapproved for the following reasons
Permit No. �abb q "5-3 3 Date Issued /U I a -0
No. d S3 3 Fee OJ
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:�✓
� Yes
PUBLIC HEALTH-DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
ftprication forMtqossal *pgtem Construction Vermtt
Application for a Permit to Construct( )Repair(lam-Upgrade Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. $g 14 1'C_0 4 /mil W y Owner's Name,Address and Tel.No.
Assessor's Map/Parcel
+ Installer's Name,Add, ss,and Tel.No.,fag'y24 Designer's Name,Address and Tel.No. :OCR-833- -9/7-7
/-XX,!goll 1/s a f G 4/a
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 gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applica le) T.ys51-1411 Z)_/JDX -�S 0,0 15he �Yc/
1= i = U(/
Gl�' �i' .St°O/9� Gyp r ham-! � /?r_
r,
h
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 `andd off ealt .
Signed 1 4 Date
Application Approved by cn �. �� -�• Date I�"�� o c/
Application Disapproved for the following reasons
Permit No. a Up A -S 3 3 Date Issued 1 U -7
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABL-E, MASSACHUSETTS
' Certificate of Compliance
THIS IS TO CERTIFY,that the On-site,Sewage Disposal System Constructed( )Repait'ed`(*--)Upgraded( )
Abandoned( )by ✓oS G{Qr; r�t � 11�v OS r ,.. .
at �i g IVW e l/,�4`'641.0 y/ 6Zl.�l�S yS ` �S has been constructed in accordance
with the provyisions of Title 5 and the for Disposal System Construction Permit No.oZ��� �3 dated �� / • l
Installer t/o6e, Li ye Islon-a.S Designer O*V/
The issuance of this permit shall not be construed as a guarantee that the s em ill fun•tion as des' ned.
Date ID - 0`•o lq Inspector All • s _
t
—4f ——
I No. /-533 Fee Ido —
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
Duigont *p!5tgM Construction ermit
Permission is hereby granted to. onstruct(_ )Repair( ��prade( )Abandon( )
System located ate=
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided: Construction must be completed within three years of the date oft is p it.
-o
Date:_ 1 ' ! 'A`Pkgved by
1
k
TOWN OF BARNSTABLE�
LOCATION 14MEl"4 W144/ SEWAGE # 2002-6ZI
VILLAGE �:'��✓�S dlili1lS ASSESSOR'S MAP &LOT !f1- d 3/
INSTALLER'S NAME&PHONE NO. 30L 'y-2D `I7 LF ez--'V�
w SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) z2-S�d dr �,Ul�/l (size)
NO.OF BEDROOMS
BCJILDER OR OWNER
PERMTTDATE: l0 -/2-0 y COMPLIANCE DATE:
Separation Distance Between the:
Feet
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility
Private Water Supply Well and Leaching Facility (If any wells exist Feet
on site or within 200 feet of leaching facility)
Edge of Wetland and Leaching Facility(If any wetlands exist Feet
within 300 feet f leaching facility
Furnished by
�2
Town of Barnstable
o Regulatory Services
Thomas F.Geiler,Director
Public Health Division
Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office:.508-862-4644 Fax: 508-790-6304
Installer&Desiener Certification Form
Date: Dc C r rz `
Designer. ►4U t� JJbW V
I Installer: �-eio4
Address: . " Address:
vA-JPV\M M4 D0531 0,,5,r r:,o s kOn
was issued a permit to install a
(date) (installer) - .
septic system at L Y b ed on a design drawn by
(address} T F T
dated I(D O`�
(designer)
V y:
t certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system)but in accordance with State.&Local Regulations. Plan revision or
certified as-built by designer to follow.
(IhstaHer7s Signature)
' - V1 IC ,
s Signature) (Affix
s
P Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVLSION. CERTIFICATE
OF COMPLIANCE 'WILL NOT BE ISSUED UNTIL BOTg THIS FORM AND AS-
BUIL3'CARD ARE RECEIVED BY THE.MRNSTABLE PUBLIC IIEALTH DIVISION.
THANK 3�OU.
Q:Health/Septic/Designer Certification Form
+� TOqq��!fZNSTABLE
ee ,amt-a-iT OLO CATION l,yf L-9 WAGE
VIT7;sLAGE f�1Ai2$TrGVS 14/&-SASSESSOR'S MAP & LOT I 03 .�
INSTALLER'S NAME & PHONE NO. brCD tj(CAV14r1A14
SgPTIC TANK CAPACITY /U11DL
r
.Ll ACHING FACILITY:(type) - 10Z�b,!�FL (size)7"vXSl"r, ``'�3
NO. OF BEDROOMS 3 PRIVATE WELL OR PUBLIC WATER C��L
BUILDER OR OWNER /j��.s/�� 66tj11,& J6
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No t/
f1rl� 7 Lti
1
Li
, o
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliration for Diti-pitial Work.6 witrnrtion antit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
S st at:
/
sca - -
. L t 'Iddres
r � or Lot No.
...............................---------- .- _... ....:.. ...Owner
✓
ess
Installer AddressPQ
Q Type of Building Size Lot..- feet
U Dwelling— No. of Bedroom,.,.�.. - -_. _.-._.__--..__.E�pansion Attic ( ) Garbage Grinder ( )
0.4.4 Other—Type of Building ......(1 v K_.2�1/ 0. of persons---------------------------- ,Showers ( ) — Cafeteria ( )
a' Other fixtures ------------------------------- ---
d -•--...
W Design Flow.--.......5 ........................gallons per person per day. Total daily flow......... ........_1- ..-. gal9 1 ns.
W Septic Tank—Liquid capacity/
Length..8.-_�.-.- Width_...-r,�...`.... Diameter................ Depth-.,��.......--
x Disposal Trench— No. .................... Width.................... Total Length..--............... Total leaching area....................sq. ft.
Seepage Pit No-----/............. Diameten/c.).....--... Depth below inlet-----4:; .......... Total leaching
Z Other Distribution box ( Dosing tank ( )
'-' Percolation Test Results Performed Date.-- .
ZZ
a
1 Test Pit No. I�� 5..minutes per inch Depth of Test Pit ".. ���.... Depth to ground water.. . ..
f% Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
L" �..........................................................
0 Description of Soil.....�, ...
x
W --•••-----------------------••-- --.....------•---••-----------'•--'------------•----------....---•'-----------------------------•-•--•--•----------------•-------•--••-----••-•---••-••'-•--•--•-------
VNature 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 TITLE 5 of the State Environ ental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compli e has eui sued by the b rd of heap
SIne ---- - - ------- .. ... ...._.i...... 1l
Dace
Application,Approved By ..... . ....... .-/...'2............................... Dace .....-..
Application Disapproved for the following reasons: ......... ... ... . -- ....... ............................... ................. .
-------------------------------------------------------------------------------------------------------------- ---- ----------------------------------------------------------------------------- ---- ----------------------------------------
Permit No. 9 :... Issued 3. � �S-�
.
Dace
THit COMMONWEALTH'OF MASSACHUSETTS V
BOARD OF HEALTH - -
TOWN OF BARNSTABLE
Apphratiun for Dispuual Wurk,i Towitrnrtiun rnmit
Application is hereby made for a Permit to Construct ( e/) or Repair ( ) an Individual Sewage Disposal
System,at:
............................................................. � .._.,.... ----------------------..............................................................
- .....................•--•---.....-- --.._.................------......... ..............................................\Ad ess
----••-- -- _ -„e �. -------------
- . -----....
� Installer Address /�//
UType of Building Size Lot----��l..i--�5--2--Sq. feet
.-t Dwelling— No. of Bedrooms----------
----------------------- ----Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building of persons____________________________ Showers ( ) — Cafeteria ( )
a' Other fixtures _______________________________ _ _ _
w Design Flow......... S�........................gallons per person per day. Total daily flow-____...�._ .............................J� gallons.
WSeptic Tank—Liquid capacit���4-1JgalIons Length_____�____ Width_-_._ ------- Diameter................ Depth_______---.
x Disposal Trench—No. .................... Width....... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No------1............ Diameter../<=;,..._____ Depth below inlet............... Total leaching area.... ...
Z Other Distribution box Dosing tank
`-' Percolation Test Results Performed by.� _� �.___ `'.j'f t-s __-___-__ Date.9,�Z"Z�'s/
a 7.- •
Test Pit No. I. ; ._minutes per inch Depth of Test Pit; . ____ Depth to ground water__AJ 6- «-.
fit Test Pit No. 2................minutes per inch Depth of Test Pit._.______..-____-.-- Depth to ground water........................
a --•----»-- ----------------------------------------------------------------.............................................................................
O Description of Soil...... •--- ? - ------ .� ..........................................................
W v
U .....------•----•-------------------•••-•--••---•-•-••-----...-•--------------------•----------------------•----------------•-------------•----•---•-•---••-•----------•---••••-•--•---------•--•--------
w
VNature 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 TITLE 5 of the State Environmental 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, .......% z� .� ,-------1)ee<�.(-:/ i�. ......3.�"..2-.�./`
//� Dare
Application.Approved By ��i.. 1. . C LL ':,.-- ---,1�� ----....?-../.. 7.-- �S
/ .................................. Date
Application Disapproved for the following reasons- -----------------------------------------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------- ...-----------------------------------------
..............
. . -----------------. ---.....---------
Date
Permit No. ......_.... ✓�'1` - ........ Issued ------------------. '."" .._..5-- ----------
Date
_ ......._,.. .�.�.o._R.._..�> -------4----_.__�.�._---_—---.a--m s— -----_..�—._._.,-------_,.�.__ —
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
C11ertif rate of Tomplinure
THIS IS)'O. CERTIFY, That the Individual Sewage Disposal System constructed ( ✓ ) or Repaired ( )
b ....... ... /% --------------- ---- --------------._ ---------.-.._..._-------------...._..------------._....---------...._.........._--- ..._...._.. -- -- ...._........ .....
y 1 Installer
at ........ -. v L! C./�t. I� 1� --- --f -_....�1G W-!... .. ........ .. ..................... . . .....
has been installed in accordance with the provis]ns of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. ..,E�'._�a7-.- 4f,?__...._.._.. dated ...3 /.. ...-. ... _.._.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT IiE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE------------- ------------ !.. ...... 1 --- Inspector ._ ------ ---- --------------- ---------------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE ff GD
s FEE..l....................
Uispoal Work,5 Tunotrurtiun "ermit
Permission is'hereby granted---`-� '/iT. 'L./J- ---------------------------------------------•-------------------------•----..............--
to Construct ( V) or Repair ( ) an Individual Sewage Disposal System,
. ---------------------------------•--------•----.....---......
at No. 's stru �( �.� /�,1�-•--••---.... ....._.r _ /, I.
Street y
as shown on the application for Disposal Works Construction Permit No.lS=���� Dated-_.�'f_/............................
f �^ •\, '•
.......................................
Board'of Health
DATE................................................................................ r�
FORM 36SOS HOBBS 6 WARREN,INC..PUBLISHERS
\ TEST HOLE LOG
TEST BY: WELLER&ASSOC.
WITNESS: _ -
PERC RATE:
i
o
ell may" YS 5
N Y .S
� .
�1 F=
0;
�2-Ni Y
DESIGN DATA
DAILY FLOW:-C3�feOO�S- /�o = 33c� 'r >.
SEPTIC TANK: x 150%= ' ie95
USE:/ODG, e'-9C,/-9Z--c-4 57 , c,,'c -��,Jr_
LEACHING FACILITY:
jZ USE: .���..G'XG'G,P..�/Z'c�a= STD 4r—
s� ss, f/f/ CAPACITY:
SIDEWALL: /88 sX a 5= V2,1 z.
BOTTOM: 23,5 :L 5
TOTAL: 15 7 �
PIPE TO BE LAID 2"LAYER OF 3/8"PEASTONE
LEVEL _FOR 2' OUT OF OVER 3/4"-1 Ii.2" WASHED
DISTRIBUTION BOX STONE ALL AROUND
TOP OF FOUND:
@EL. SS o0
10" 14" �-
.5-/, z,
� o
.Sa
ALL PIPE TO BE 4"DL4.SCH 40 PVC z G Z
RAISE ALL APPLICABLE MANHOLE /o'
COVERS TO WITHIN 6" OF I+'INISH
GRADE
THIS SYSTEM IS NOT DESIGNED FOR
THE USE OF A GARBAGE DISPOSAL
SEWAGE SYSTEM PROFILE
SCALE: 1"=10'
i
GENERAL NOTES
1. CONTRACTOR TO BE RESPONSIBLE FOR THE
SITE-SEWAGE PLC LOCATION OF ALL UTILITIES,ABOVE AND
`A UNDER GROUND,PRIOR TO ANY CONSTRUCTION
FOR k OR'EXCAVATION.
ICJ i?,yt, : d l
2. INSTALLATION OF SEPTIC SYSTEM TO BE IN
r
PREPARED FOR ' CO.M. PLIANCE WITH 310 CMR 15.00: TITLE V.
3. THIS PLAN IS NOT TO BE USED FOR PROPERTY
k �s�{N of trp� LINE DETERMINATION.
SCAL]E:,_/)s_ a7E0 DATE:
"A
r :Sib
WELLER & ASSOCIATES
P. 0. BOX 119 YARMOUTHPORT, MA. 02675
(508) 362-8131 APPROVED BY:
TEST HOLE LOG
DATE.:_�/ ��n� 99 �D87_3 3.
TEST BY:WELLER&ASSOC.
WITNESS: O . i9.P.R`
PERC RATE:
f J
nJ
�\
\ (z�
o ,
G 'y
1 5� DESIGN DATA
1' DAILY FLOW:-C3�"6co2u3 x it o - 33ci��
fir, SEPTIC TANK:.�3�
USE'loos' �9C•/�.����� ,1*"7`c . :?+.�.�
LEACHING FACILITY:
USE: �i� -1'XG.le,
CAPACITY:
SIDEWALL: S5 y7/.z
BOTTOM :'3 �•c� p
\ . TOTAL:
PIPE TO BE LAID 2"LAYER OF 3/8"PEASTONE
LEVEL FOR 2' OUT OF OVER 3/4"-1 1/2" WASHED
DISTRIBUTION BOX STONE ALL AROUND t.
TOP OF FOUND.
@EL. S'S.oa
10" 14„
87
3/• S2 /, z7 �/•oz G
ALL PIPE TO BE 4"DIA.SCH 40 PVC Z' �- z
RAISE ALL APPLICABLE MANHOLE
COVERS TO WITHIN 6" OF FINISH
GRADE
THIS SYSTEM IS NOT DESIGNED FOR
THE USE OF A GARBAGE DISPOSAL
SEWAGE SYSTEM PROFILE
SCALE: 1"=10'
GENERAL NOTES
1. CONTRACTOR TO BE RESPONSIBLE FOR THE
SITE-SEWAGE PLAN l
LOCATION OF ALL UTILITIES,ABOVE AND
UNDER GROUND,PRIOR TO ANY CONSTRUCTION
FOR / k OR EXCAVATION.
2. INSTALLATION OF SEPTIC SYSTEM TO BE IN
COMPLIANCE WITH 310 CMR 15.00:TITLE V.
PREPARED FOR
3. THIS PLAN IS NOT TO BE USED FOR PROPERTY
/A/G- ���Hof �' LINE DETERMINATION.
SCALE:,�2.s d DATE: �!�- G / :5 �'� - �a C'1 _(y
NO
WELLER & ASSOCIATES
P. O. BOX 119 YARMOUTHPORT, MA. 02675
508 362-8131
_ � � 'APPROVED BY:
6
is ASSESSORS MAP: --- -- TEST HOLE LOGS
PARCEL: ?l -- D _. ---
--- - _ _ NOTES:
FLOOD ZONE: _tti_UT----�"!-�'r�� - - - SOIL EVALUATOR:_1 1AVI �� t�lL,
1� - WITNESS : v
REFERENCE: i.UrGi��► �' �� -_. �'� DATE: nLtblRiC�D K
�o —__-- --- - -� 1) The installation shall comply with Title V and Town of Barnstable Board of
(� t PERCOLATION RATE: G N(1 tom- ,
Health Regulations.
'BTU --- - — - ^— 2) The installer shall verify the location of utilities, sewer inverts and septic
TH- TH-2 components prior to installation.
6k4 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8"per foot.
� 10 CPAs ` 4) This plan is not to be utilized for property line determination nor any other
D LO 5 f ,�Y purpose other than the proposed system installation.
b� �� 5) All septic components must meet Title V specifications.
6) Parking shall not be constructed over H10 septic components.
2 — 7 The property is bounded b property corners and property lines as depicted.
LOCATION MAPC4_1 'S) ) P PertY � YP P Y P P Y P
�<i
.44
1U1 _ �F� '�/ 8) The property owner shall review design considerations to approve of total
/ number of bedrooms to be considered for design. Receipt of payment for the
plan and installation based on the plan shall be deemed approval of the
number of bedrooms.
l 9) The existing leaching system shall be pumped and backfilled per Title V
l Abandonment Procedures.
�rl 10)System components to be 10 feet from water line.
?'- � -- 11)Septic tank to be a minimum of 1000 gallons. If tank is less than 1000 gal.,
then replace with 1500GST.
SEPTIC SYSTEM DESIGN
�j FLOW ESTIMATE
4
l BEDROOMS AT GAL/DAY/BEDROOM - GAL/DAY
'SEPT I C TAN
1
GA'-/DAY x 2 DAYS - t �7 GAL
/ } USE JG';_)OGALLON SEPTIC TANK LE:"j1�t(w,"')
` r SOIL ABSORPTION SYSTEM
` - - I ► 2 ��� a 'jXL�L T �b 2 wit-t�5
DE AREA: Z X 7J4 + 1 S X Z X �� � �sZ
BOTTOM AREA: IS ' -A D -
SEPTIC SYSTEM SECTION
i rw� I �w,�, uuC, btu 9a
N
"'mac'
[000 GALPT
SEPTIC TANK -_ 99 , --
`.
Zy x �3
Cp ,.
SITE AND SEWAGE PLAN
LOCATION :
qN��LJ J4 W
N1�4�L5Tb MXJ:->p M)4
PREPARED FOR : �;/tti/J DI-l"
o '
SCALE: /�/_
DAV I D B . MASON RS DATE: /0 7
W
K
o DBC ENVIRONMEN AL DESIGNS
- -- EAST SANDWICH . MA
_ DATE HEALTH AGENT
W r ( 508) 833- 2I77
3
W
2