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Home My WebLink About0485 BAXTERS NECK ROAD - Health 485 BAXTER NECK q4, M. MILLS A=075-007.008 a, i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal.System Form - Not for Voluntary Assessments 485 Baxter Neck Rd. Property Address JACKSON, GARY P&JEANNE OCONNOR Owner Owner's Name information is required for every Marstons Mills Ma 02648 5/8/2013 r page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information (� on the computer, \' use only the tab 1. Inspector: `J3 key to move your cursor-do not Sean M. Jones use the return .Name of Inspector key. S.M.Jones Title V Septic Inspection my Company Name 74 Beldan Ln. Centerville Ma 02632 Cltyrrown State Zip Code 774-248-4850 smjonestitle5@gmail.com SI4522 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 csa 201"3, Inspectors Signature Date er � The.'system inspector shall submit a copy of this inspection report to:the Approving Authority(Board C o Health or DEP)within 30 days of completing this inspection. If the system is a shared system.or �= h s'-"'design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the o � 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. 51b 1,5 t5ins•3/13 Title 5 ONInsn Subsurface Sewage Dispos 0 al ystem•Page 1 of 17 iR l Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 485 Baxter Neck Rd. Property Address JACKSON, GARY P&JEANNE OCONNOR Owner Owner's Name information is required for every Marstons Mills Ma 02648 5/8/2013 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection. Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The dwelling located at 485 Baxter Neck Rd Marstons Mills is served by a Title V septic system consisting of a 2000 gallon 2 compartment septic tank, distribution box and 7 500 gallon leaching chambers. The system was found to be in proper working condition at the time of inspection. 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 M 485 Baxter Neck Rd. Property Address JACKSON, GARY P &JEANNE OCONNOR Owner Owner's Name information is required for every Marstons Mills Ma 02648 5/8/2013 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 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 , 485 Baxter Neck Rd. Property Address JACKSON, GARY P &JEANNE OCONNOR Owner Owner's Name information is required for every Marstons Mills Ma 02648 5/8/2013 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® 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 day flow t5ins•3/13 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 485 Baxter Neck Rd. Property Address JACKSON, GARY P &JEANNE OCONNOR Owner Owner's Name information is required for every Marstons Mills Ma 02648 5/8/2013 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® 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. ❑ ® 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- 1 0,000g pd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 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 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , 485 Baxter Neck Rd. Property Address JACKSON, GARY P&JEANNE OCONNOR Owner Owner's Name information is required for every Marstons Mills Ma 02648 5/8/2013 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® 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? ® ❑ 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): 7 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 828 gpd provided t5ins•3f13 Title 5 Official Inspection Forth: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 485 Baxter Neck Rd. Property Address JACKSON, GARY P &JEANNE OCONNOR Owner Owner's Name information is required for every Marstons Mills Ma 02648 5/8/2013 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): Detail: 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(gpd) 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 I l Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 485 Baxter Neck Rd. Property Address JACKSON, GARY P&JEANNE OCONNOR Owner Owner's Name information is required for every Marstons Mills Ma 02648 5/8/2013 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: routine 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 li Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 485 Baxter Neck Rd. Property Address JACKSON, GARY P &JEANNE OCONNOR Owner Owner's Name information is required for every Marstons Mills Ma 02648 5/8/2013 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: system installed 4/13/1999 per town records Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 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.): Joint were ok, no leaks, vented through the roof Septic Tank(locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 2000 gallons 2 compartment 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 M , 485 Baxter Neck Rd. Property Address JACKSON, GARY P&JEANNE OCONNOR Owner Owner's Name information is required for every Marstons Mills Ma 02648 5/8/2013 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? tank was cleaned at time of inspection Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank was cleaned art time of inspection and should be done again every 2 years for proper maintenance. Inlet and outlet tee were intact, water level was even with outlet invert, tank was not leaking and was structurally sound. 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 t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts ugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 485 Baxter Neck Rd. Property Address JACKSON,GARY P &JEANNE OCONNOR Owner Owner's Name information is Marstons Mills Ma 02648 5/8/2013 required for every 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 F ow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3113 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 M 485 Baxter Neck Rd. Property Address JACKSON, GARY P &JEANNE OCONNOR Owner Owner's Name information is required for every Marstons Mills Ma 02648 5/8/2013 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box if resent must be opened) locate on site plan): ( P P ) ( P ) 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.): Distribution box was in good condition, no rot, water level was even with outlet invert. PumpChamber locate on site plan): ( P ) Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/1:3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 485 Baxter Neck Rd. Property Address JACKSON, GARY P &JEANNE OCONNOR Owner Owner's Name information is required for every Marstons Mills Ma 02648 5/8/2013 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 7x500 gallons ❑ 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.): s.a.s. was found to be dry with no sign of past hydraulic overloading. Cesspools (cesspool must be pumped as part 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 ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments , 485 Baxter Neck Rd. Property Address JACKSON, GARY P&JEANNE OCONNOR Owner Owner's Name information is required for every Marstons Mills Ma 02648 5/8/2013 page. Cityrrown 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.): 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 485 Baxter Neck Rd. Property Address JACKSON, GARY P &JEANNE OCONNOR Owner Owner's Name information is required for every Marstons Mills Ma 02648 5/8/2013 page. Cityirown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately lour A Z 51) i3'Z sr 3 SZ i A 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 485 Baxter Neck Rd. Property Address JACKSON, GARY P &JEANNE OCONNOR Owner Owner's Name information is required for every Marstons Mills Ma 02648 5/8/2013 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12'+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Design plan dated 7/22/1998 indicates that no groundwater was encountered at at 11'and system is designed to have a seperation of 6'+ between bottom of s.a.s. and adjusted high water elevation. Bottom of leaching chambers is approx 4' below grade. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y 485 Baxter Neck Rd. Property Address JACKSON, GARY P &JEANNE OCONNOR Owner Owner's Name information is required for every Marstons Mills Ma 02648 5/8/2013 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 t ' \ C`•OMIMOI WEALTH OF KkSSACHUSETTS z EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS. DEP:ARTMENT OF.ENvIRONMENTAL -ROTECTIO_ TITLE 5 01-7ICLA0L. INSPE+CTION FORM—?TOT.FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A 'CERTIFICATION �- s_ U'�S'-�o07-� PropertyAddrass: �� tz*W ";0/v�� Owner's 1 2me ' (. Owner's Addres . `" " -Date of Inspection: A (l2t('/171.�� C�, Name of Inspecto prase print io 10 ` • Company Mailind,Address: 1 A Telephone Number: sISO R-° �J CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on.site sewage disposal systems.I am a DEP " approved system inspector pursuant to Section 15.340 of Title 5(3.10 CMR 15.000). The system: Passes . Conditionally Passes Needs Further Evaluation by the.Local Approving-Authority t cz:2 ems, Inspector's S3gnfltLre: Date: The system inspector shall_submit a copy of this inspection report to the Approving Authority($4ard of Health.o^i r DEP)within 30 days of completing this inspection. If the system is.a shared system or has a desn flow of.t110,001?::-: gpd or greater,the inspector and the system owner shall submit the report to the appropriate regid al officUof the DEP.The original_ should be sent to the system owner and copies sent to the buyer, if applicable, nd the apYprovigg authority. ' 3'Y] 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 page l I • ..Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FO R VOLUNTARY ASSESSM ENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART A CERTIFICATION (continued) Property Address: Owner. Date of . spectioh: Q Inspection Summary: Check A,B,C,D or E./ALWAYS complete.all of Section D A. ystem Pa 11 sses: I have not found any information which.indicate. s that any of the failure criteria described in 310 CMR 5 a 1 .�03 or in 310 CMR 15.30, exist.Any failure criteria:not evaluated are indicated below, e low. 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: 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 2.0 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 se tic tank-.as a PP Y roved b the Board of Health. P 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 h n 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: Page 3 of I! OFFICIAL INSPECTION FOR-M .-:NOT FOR VOLUNTARY ASSE T SSMEi�TS SUI3SVI All SEWAGE DISPOS`AI_;SYSTEM P_VSPECTION"FORM PART:A CERTIFICATION(continued) Property Address: 1. Owner, Date spection: JC C. rurther.B'valuation 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(I)(b) that the system is not functioning in a manner which will protect:publir health,safety and'the environment: Cesspool or privy is within 50 feet of a'surface water — Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. . System will fail unless the Board of Health (and Public,Water ,Supplier, if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system (SAS)and the SAS is,within 100 feet of a surface water supply or Tributary,to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1-of a.public water supply. The system has a septic tank and S AS and the SAS is within 50 feet of a private water supply well. _ The system.has aseptic 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 anc 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 thatno other failure criteria are triggered. A ropy of the analysis must be attached to this form. 3. Other: 3, Page 4 of. I I OFFICIAL INSPECTION:FORPrI:--.N T FOR:YOILIJNTARY'ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION,FORM, PART A CERTIFICATION(continued) Property.Address: s Owner: Date of I spection: ' 40,d6969 D. System Failure Criteria applicable to all systems: You must indicate"yes" or"no"to each.of the-following for all inspections: Yes No _ Backup of sewage into.facility or system component due to overloaded or clogged SAS.or cesspool Discharge or ponding of effluent to the surface of the ground.or surface waters due to an overloaded or clogged SAS or cesspool 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 %z day flow . Required pumping more.than 4 times in.the last year NOT due to clogged or obstructed pipe(s).Number of times pumped y Any portion,of the.SAS;cesspool or privy is below high ground water elevation. _ v Any portion of cesspool or privy is within I00 feet of 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. _ 1/ Any portion of a cesspool.or privy is within 50 feet of a.private wafer supply well.: Any portion of:a cesspool or.privyis:less than 1.00 feet but greater than.5.0 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 colifor.m bacteria and`volatile organic compounds indicates that the-well is free from pollutim 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.) r�t✓ (Yes/No)The system fails. I have determined.that,one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore-the system fails.:The.system owner should contact the Board of Health to:determine what will be necessary,to.correct the failure. E. Large,Systems: To be considered a large system the system must serve a.facility-with a design flow of 10;000 gpd.to 15,000 5pd- 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 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 3,10 CMR 15.304.The system owner should contact.the appropriate regional office of the Department. Page 5 of I OFFICIAL INSPECTION FORt`✓I.—NOT FOR V OLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSP.ECTIONFORVI PART E CHECKLIST Property Address: g, L �7� AZ Owner: r t,, Date of pecticn: Check ifthe following have been done.You must indicate"yes" or"no" as to each of the following: Ye 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? ZHave large volumes ofwater been introduced to the system recently or as.pari 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 ? ' _ 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? . L/ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Yes id— no Existing information. For example, a plan at the Board of Health. Determined in the field. if an of the failure criteria related t .( y o Part C is at issue approxtmation of distance is unacceptable) [310 CMR 15302(3)(b)l 5 i Page 6-of l l OFFICIAL INSPECTION FO.RM.—NOT:FOR_VOLUNTARY:ASSESSMENTS SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART".C SYSTEM INFORMATION Property Address.- Owner. j 1 Date,of, spection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design)---?. Number of bedrooms (actual).: DESIGN flow based on 310 CMR 15.203 (for example: 11.0 gpd x 4 of bedrooms): `270 Number of current residents:.- Does residence have a garbage grinder(yes or no): ��' Is laundry on:a separate sewage system(ye or no): :[if yes separate inspection required] Laundry system inspected(y�.or no):A Seasonal use: (yes or no): - //,e� Water meter readings, if available (last 2 years usage.(gpd)): O q '1 4�,f/li� .. 16.000 Sump pump (yes or no): V Last date of occupancy: ` m ✓L.� -�� r�eF �e�:�ed� COMMERCIAL/INDUSTRIAL//O Type of.establishment:, Design flow (based on 310 CMR I5.203): gpd Basis of-design flow(seats/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: ,l Was system pumped as part oftlie inspectio (ye o no): If yes, volume pumped: gallons --How was quantity pumped determined?. Reason for.pumpinl-: TYPE F SYSTEM eptic 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 a copy of the.DEP approval _Other(describe): proximate age of all cop po ents, da e instal (if known ".d soLi ce of mao ation UA Were sewage.odors:detected when arriving at the site VS or no,,j f� 6 . f Page 7 of l:.l OFFICIAL INSPECTION FORM—NOT FOR'VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM-INFORMATION (continued) Property Address: i G ' Owner{-- A/, Date of�nspection: '� (� (10 BUILDING SEWER (locate on site plan) A/0 Depth below grade: Materials of construction:_cast iron 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:Zoocate'on site plan) Depth.below grade,: { Material of construction: ncrete.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: Sludge depth: Distance from top vo.f sludge to bottom of outlet tee or baffle: . Scum thickness: j Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffler How were dimensions determined: ( , ; . �f>M Comments (on pumping recommen ations, inlet and outlet tee or baffle condition, structural integrity;liquid levels as related to outlet invert,evidence of leakage, etc.): V f� of GREASE TRAP/ (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 (on pumping recommendations; inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc:): 7 - Page 8 of I .'OFFICIAL-INSPECTION FORM—N.OT.TORN OLUNTARY ASSESSMENTS; SUBSURFACE-SEW-AGE DISPOSAL, SYS.TEIVI INSPECTION FORM PART C SYSTEM INFORMATION(continued). Property Address: Date of pection: ' a.C�,a TIGHT or HOLDING TANK: (tank,ATust oe.pumped at time of inspection)(loc.ate.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: —t—Zif present must be opened)(locate on site plan) Depth of liquid level above outlet inver:.'��'�/"'` !I - Comments (note if box is level and distributionto outlet.: ual,.any evidence of solids carryover, any evidence of - Teakage into r ou of bgx, ete : R e � f/ / i e ' ' PUMP CHAMBER'•(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.): a Page 9 of 11 OFFICIAL INSPECTION FORM.—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: r . ?66441 Owner: _ �' ,' l�LJL ,. � Date of I pection: SOIL:ABSORPTION SYSTEM, (SAS): � (locale on site plan, excavation not required) If SAS'not located explain why: Type _ chig.pit , number: i s � ag chambers,number: le'aching.galleries, number: leachinc,trenches,number, length: .leaching fields,minber, dimensions: overflow cesspool, number: .innovative/alternati.ve system— Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation; A. l I cesspool must be pumped, a„ art of ins ection locate on site Ian CESSPOOLS: ( p )( ) ,� �� P P P ?dumber and configuration: Depth'—top.of liquid to inlet invert: Depth of solids laver: 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: ( (locate on site plan) Materials of constriction: Dimensions: Depth of solids: Comments (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation,,etc.):. 9 Pace 10 of l 1. OFFICIAL INSPECTION-FORM—.N 0'T FOR VOLT1 (ASSESSMENTS . SUBSURFACE SEWAGE DI SP SAL SYSTEIM INSPECTION.FORM. 'PART,C. SYSTEM INFORMATION(continued) Property Address: %`: .. . Owner:, Date of)'spection:.' SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a.sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet:Locate.where public water-supply:enters the buildingF�T-E . P by LAO) i f Page I I of I I OFFICIAL INSPECTION FORM, -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL-SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: .( Owner.. i/ Bate of I s ection: � C,, 7,4- SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to groundwater /$—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: Observe&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 USOS database-explain: You must describe how you established the high ground water elevation: d ob & Il I Permit Number: Date: Completed by: �li`�^ 0 HIGH GROUND-WATER LEVEL COMPUTATION Site Location: f �(/� :�-�� /i'/.A//`/ Lot NNo. Owner:( &e , /yCe Address: �7>/�J fl /-•�i�G'[% d�� Contractor: [' Address: STEP 1 Measure depth to water table tonearest 1/10 ft. .............................................................................. .Date. /1 ,�_O 45 month/day/year STEP 2 Using Water Level-Range Zone and Index..Well:Map locate site and-determine: n ✓�� OA AID Opna#e index well.................................................... Af OWater-level range zone ..................................................... STEP 3 Using monthly report "Current Water':Resources Conditions" determine current depth to 'ovate level for index well .......r:............ To month/year ...._._ STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A), current depth to water level for index well (STEP 3), and water-level zone (STEP 2B) determine water-level adjustment ........................................................................................... STEP 5 Estimate depth to high water by subtracting the water- level-adjustment (STEP 4) from measured depth to water levelat-site (STEP 1) ....................:........................................................................................ f� Figure 13.—Reproducible computation form. 15 .�� .. . a ,.,�..wTz., _. ., _..... ._... _. __..... ... ... .: .... a . � ! ,:. ffA TOWN OF BARNSTABLE LOCATION' SEWAGE # VILLAGE ASSESSOR'S MAP& LOB INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY caw f LEACHING FACILITY: (type) (size) X f NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: / CO LIACE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) ' Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by (p 3 2 Fee No. ' THE COMMONWEALTH OF MASSACHUS TTE S Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZippYication for Oigpogar *p5tem Cougtruction Permit Application for a Permit to Construct(,,e)Repair( )Upgrade( )Abandon( ) ❑Complete System O Individual Components Location Address or Lot No. S A f>A y N to G-G�C F(� Owner's Name Address and Tel.No. -7 61-I G 9' ZZ M A:-5 la U 1"A t L LS PA i Lc s '1-\U G—p-(Z EA LTA 1 .,�A Assessor's Map/Parcel 7 S ,J to-7^ 008- v;99 Cp m-mo Sic �0 -,,voo7 Y`�►A O20(oz Installer's Name,Address,and Tel..No. D;�ss}}gner's Name,Address and Tel.No. Qzgr 3 -7 k +AA Type of Building: -T Dwelling No.of Bedrooms Lot Size 43 SS I sq. ft. Garbage Grinder( IU Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow SZ9 gallons. Plan Date Ju t.,c 7-21 19 98 Number of sheets 2 Revision Date L Title S t T S PLC 1P20PO5ED SEPTIC SYSg�-w1 �.oT 8� gAxTE-e 9�t,V Size of Septic Tank TC;6O &LL0Q TIC- Type of S.A.S. 12xG-7 LC-Aee,%w6 Clog Ls Description of Soil 0'` 1 t - A 4 6 LbP- k S ,350l L_ i - 1 C-L CA^) A G-OSAA30 BJb \&1A rE _ t—:�C-0U 1Q Tfi-R_E:Q Nature of Repairs or Alterations(Answer when applicable) 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 issue b this Board of Health. p Signed ate. Date / Zl 9 Application Approved by Date Application Disapproved for the follo ing reasons Permit No. 9' _t / 7� Date Issued No. - L / Fee �J <J�J t THE COMMONWEALTH OF MASSACHUSETTS , _ Entered in computer. -- "PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHU'jETTS Ye ` f 01pprication for Di-4pozar *pgtem Con0truction Permit Application for a Pe t to Construct(v )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. A 6AxN7_=Y_Q C.CAL f_'0 Owner's Name Address and Tel.No. _ -7 8 i--7 G 9' 2 ZZZ M-Ae5TaU t"\IL.LS MILt-S ZU C � e_QaAC_1-� U\ tZ. SS�p p Assessor's Map/Parcel -7 S / co-7- OOg- 129 CAM TON ►` I VS )eV�000 Y`�1 OZOG Z Installer's Name,Address,and Tel.No. D gner's Name,Address and Tel.No. W9R-Ee-SuL. v4iv FC V. t� �v,�� r� y lz —Et2�/►LSEA Type of Building: Dwelling No.of Bedrooms S Lot Size 43 l sq.ft. Garbage Grinder( Aj Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 550 SO% gallons per day. Calculated daily flow 829 gallons. Plan Date Ju L�f ZZ j ►9 98 Number of sheets 2 (a Lot Revision Date l�0 t� LZ Title S T� i9LFw P(2OP05c SY �Em. -0 �EP-n C - 6A D pAx taZ14aj,-_ zc> Size of Septic Tank ?-Cb0 C-)ALL0 Q Z-Co w\P Type of S.A.S. l Z&G-7 k GAC F'•,vUG C►'uawvB LS Description of Soil 1 A C0SAruQ r". Nature of Repairs or Alterations(Answer when applicable) 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 issue by this B and of Health. Signed %�-� Date 20 cf Application Approved by Date;7_-A Application Disapproved for the follo ing reasons Permit No. Date Issued --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certif irate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( K )Repaired ( )Upgraded( ) Abandoned( )by at AK T-Y- A EQC OA D ^(LS TZ)YUS M 1 LC.S has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. V 70 dated Installer Designer J /-i h c3 ,l I /Ml V The issuance of this pe t/'hall n e onstrued as a guarantee that th system-will function as de J.Igg!i d/��;l�, Date / Inspectorr l�} /i/� /I r �'IffTl► 1 I V- ---�j--- ------------------------------- " No. Z> Li 7 Fee -_ THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS " Biopogar bpgtem Congtri urtion Permit Permission is hereby granted to Construct( K)Repair( )Upgrade( )Abandon( ) n System located at `BASS z Q ecr— C.b,kQ 1MA%ZS MNS �1'` t LL.S A. 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:Construc on m `t be ompleted within three years of the date of a t. �l D �j `n , Date: 1 1 Approved by r r I ;-- - - ' -��•--}�- N E C K / 1 = S 0312'SO'E 79.35' 0001, 1 1 77- PROPOSED+ ' M FMIILY DyIE1J IN0 I \ FOUNDATION IL \ ,0.5• ^ \\ // ` DECK POOL ®� ^ T� • N \ ® N p \ N N 0 67' ^ IV • = 1EI=77=CCCLI7� RESERVE AREA r I .g t 0312'SO'E 1 . PLAN VIEW Scale:11I=50' 10 CULTEC UNITS TOTAL OF (1) 330 S (STARTER) O 7.5' (8) 330 1 (INTERMEDIATES) O 6.25' (1) 330 E (END) O 6.25' SULLIVAN PgR FORATED �0.29 $ 4 PVC PIPE CIVIL y 63J5' Q N N DIST -� :�� • , • 80X 67 SITE PLAN PLAN HEW - WACHING CHAMBERS PROPOSED SEPTIC SYSTEM NOT TO SCALE AT LOT 8A- BAXTER NECK ROAD MARSTONS MILLS,MA FOR MILLS RIVER REALTY TRUST . SCALE: I"=501 DATE: JULY 22,1998 SULLIVAN ENGINEERING INC. SHEET I Of 2 OSTERVILLE,MA i ` NOTES DESIGN DATA L Water Supply ForThis Lot isMunicipol Water Single Family-5 Bedroom With .Garbage Grinder 2.Location of Utilities Shown onThis Plan Am Approx. Daily Flow=110 x5=550 GPD At Least 72 Hours Prior to Any Excavation FbrThis Septir.Tank.550 x 200%=1100 G PD ' Project The Contractor Shall Make The Required Use 2000 Gallon Septic Tank With 2Compartments. Notification to Dig Safe(1-800-322-4844) LEACHING AREA 3 The Contractor is Required to Secure Appropriate 825 GPD/0.74=1115 SF Required Permits From Town Agencies For Construction Sidewol I=2(12'+67")2=316 S.F. Defined byThis Plan. Bottom Area=12!x.67'= 8.04&F. 4 Install Risers as Required to Within 12!'of I120 SY Total Provided Finished.Grode. LEACHING CHAMBER DESIGN 5.All Structures Buried Four Feet or More or Subject All Pipes to be Schedule 40.PVC to Vehicular Traffic lobe H-20 Loading. Perforated With Capped Ends.Use 6. Septic System to be Installed in Accordance With .1-4"Distribution Dine iq Leaching 310 CMR 15.00 Latest Revision And The Town of Chambers in a 12 x67 Washed Barnstable Board of Health Regulations. Stone Fields as Shown. 7. All Piping to be Sch.40 PVC 8. Septic Tank Shall be a 2000Ga1., 2 Compartment. The First Compartment Shall Have a Volume of Not Less Than 1100 Coal.And The Second of Not Less . Than 550 Gal. 10 CULTEC RECHARGER 330 CHAMBERS IF - 15.5' FG - 14W EG/FG - 14.5' DATE: 02/14/91 11.5' No. P — 7697 12 75, 2000—CAL BARNSTABLE S. 0. H. 12.30' SEPTIC TANK 2—COMPTMTJTITLIE BOTTOM EL - 9.5' EL - 15' NOTE a1175 0 EL - 1s' BEDDING LOAM & SUBSOIL 1' EL - 14' 10' 12' 12' 12' CLEAN MED SAND 11' EL - 4' WATER EL - 1.7' No. P-7702 02/14/91 DEVELO FD PROFILF, OF PROPOSED SEPTIC SYMER LOT 230 NOT TO SCALE FINISH GRADE COMPACTED FILL 3' MAXIMUM 1/2' it - — PEASTONE DOUBLE �•' WASHED a ' ! • .4''!�'. ' STONE SULLIVAN •• ;.• CULTEC 330 ' • NO.29133 -+ CIVIL 52' IV00 CROSS-SECTION OF CHAMBER NOT TO SCALE LOT— 8A BAXTER NECK RD. SHEET 2 of 2 r: ( TOWN OF BARNSTABLE LOCATIO ; J %�: lr� ' SEWAGE # VII.LAGE ',��d�'r �1d ,' � 'N•G� ASSESSOR'S MAP &LOfi INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY OOU LEACHING FACILITY: (type) (size) X f 0 NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE:T��7� COMPL cE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by �l"1�5F =g = _ - \Y REFERENCES: Assessors Map: 75 00 Parcel: 7-8 ZONE: RE `S�. LID ID Setbacks: Front: 30'm in Side: 15'm in Rear: 15'min ID Lot 7A � N � 56 3' 9 6� `OV � 1 92.1' Lot 6A New Z Concrete O Lot 8A Foundation � N V 36.6' O v I Nj CP 011 O 41.8' N N 85°5 7'23" E (-n 1 214.06' NJ N _ Lot 9A c� 4 401302I certify that the foundation RICHARD Ft shown hereon conforms to the LHEUREUX setback requirements of the PLOT PLAN No.34312 Zoning Bylaws of the town {4i�sTEq`�� of Barnstable. IN .Y_ W, �o itiov �� Professional Land Surveyor'_ ate (Morstons Mills) Hari. NOTES: DATE: 10/NOV/98 SCALE.- 1"=40' 1.) The structure shown was located on the ground o 20 40 so So FEET by conventional survey methods on 10/NOV/98. PREPARED FOR: 2.) The property information shown hereon was Mills River Realty Trust compiled from available record information and 725 Canton Street does not represent on. actual on the ground survey. Norwood MA 02062 3.) This plan is not for recording and is not PREPARED BY: to be used for construction layout or deed lapeSury description purposes. PO Box 718 Hyannis MA 02601-0718 DWG #: C278pp1 FIELD BY: RRL/RJM (508) 790-7902 790-7905fox