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HomeMy WebLinkAbout0190 BLACKTHORN ROAD - Health 190 BLACKTHORN RvA MARSTONS MILLS , A = 047 034 1 i i Commonwealth of Massachusetts Tittle 5 Official Dnspecti®n Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 190 Blackthorne Rd Property Address Elise Snow Owner owner's Name information is required for every Marston Mills MA 02648 5-30-13 page. City/Town 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 ng out forms A General Information on f the computer, A. .``������jHIOF rMgsS use only the tab 1. Inspector �ZO 4 J� Vbqq key to move your p o?' •.�G cursor-do not ;�: JAMES .% use the return James D.Sears =1: -R', key Name of Inspector * Capewid Enterprises,LLC ��•.o� �o;�� Company NameVQ '�i,�F • ?? �•'G�`�� 153 Commercial St. iNSp������` Company Address Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S1623 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 16.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority g:d�� 5-30-13 spector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3r13 Title 5 OfHdal InspectionVFSb�Sewage Disposal System.Page 1 of 17 Commonwealth of Massachusetts Title 5 Official gnspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ' 190 Blackthome Rd Property Address Elise Snow Owner Owner's Name information is required for every Marston Mills MA 02648 5-30-13 page. cityrrown State Zip Code Date of Inspection B. Certification (cunt.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 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: ❑ 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•3113 Title 5 Official ktspection Forth: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 190 Blackthome Rd Property Address Elise Snow Owner Owner's Name requir required is Marston Mills MA 02648 5-30-13 required for every 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 pumpstalarms 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•3113 Title 5 lMidal Inspection Form:Suttsurfaos Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Fills 5 Official Inspection Foam Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 190 Blackthorne Rd Property Address Elise Snow Owner Owneras Name information is required for every Marston Mills MA 02648 5-30-13 page. Cityrrown State Zip Code Date of inspection B. Certification (cunt.) 2. System will fail unless the Board of Health (and Public Water Supplier,N 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 iindicates 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 acpapW is less than 6°below invert or available volume is less than Y2 day flow 4 t,,4 c,)/Al 6:! t5ins•3113 TWO 5 Official Inspection Forth:Subsurface Sewage Disposal System Page 4 of 17 Commonwealth of Massachusetts Title 51 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °e 190 Blackthome Rd Property Address Elise Snow Owner Owner's Name Information is required for every Marston Mills MA 02648 5-30-13 page. Cityrrown 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- 10,000gpd. ❑ ® The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system 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•3M3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 official Mspection Forums Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '< 190 Blackthorne Rd Property Address Elise Snow Owner Owner's Name information is required for every Marston Mills MA 02648 5-30-13 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 ❑ I ® 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 CM 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): na Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 t5ins-3/13 Title 5 Official hspection 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 190 Blackthome Rd Property Address Elise Snow Owner Owner's Name information is required for every Marston Mills MA 02648 5-30-13 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: The system is a 1000 Gal.tank D.Box and for infiltrators. Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): 2011-129,OOOGal 2012-16 OOOGaI s Detail: Sump pump? ❑ Yes ® No Last date of occupancy: NA 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 190 Blackthorne Rd Property Address Elise Snow Owner Owner's Name information is required for every Marston Mills MA 02648 5-30-13 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: NA Was system pumped as part of the inspection? ❑ Yes ® 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)and a copy of latest inspection of the I/A system by system operator under contract ❑ ':fight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 official pnsp ectuon Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 190 Blackthorne Rd Property Address Elise Snow Owner Owner's Name information is required for every Marston Mills MA 02648 5-30-13 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed(if known)and source of information: Tank Na/Leaching 2000-Permit 2000-339 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 28"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.): Pipeing is 4" PVC SCH 40 Septic Tank(locate on site plan): Depth below grade: 18"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: 1000 Gal. Precast Sludge depth: 2" t5ins•W13 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 190 Blackthome Rd Property Address Elise Snow Owner Owner's Name information is required for every Marston Mills MA 02648 6-30-13 page. Citylrown 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 28 Scum thickness 1 Distance from top of scum to top of outlet tee or baffle 8 Distance from bottom of scum to bottom of outlet tee or baffle 17 How were dimensions determined? Asbuilt-Tape Sludge Judge 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 at working level. Tank ank covers at 18"below grade. In and outlet tee's. No sign of leakage or over loading. Note: Tank to be maint. pumped after inspection. 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 Title 5 official pnspection [dorm Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 190 Blackthome Rd Property Address Elise Snow Owner owner's Name information is required for every Marston Mills MA 02648 5-30-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ 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•3/13 Title 5 Official Inspection Forth: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 190 Blackthome Rd Property Address Elise Snow Owner Owner's Name information is required for every Marston Mills MA 02648 5-30-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 16"x16"-25" below grade w/one line out, box is clean and solid. No sign of overloading or solid carry over. Pump Chamber(locate on site plan): 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth �of Massachusetts Tide 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 190 Blackthome Rd Property Address Elise Snow Owner Owner's Name information is required for every Marston Mills MA 02648 5-30-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number. 4 ❑ leaching galleries number. ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/altemative 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 four Hi cap infiltrator's w/4'stone. Camera out to leaching, dry and clean. No sign of over loading or holding water. No sign in D Box of leaching over loading. 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•3/13 Title 5 Official Inspection Form:SubsurfaceSewag Disposal System•Pa ge 13 of 17 Commonwealth of Massachusetts Title 5 Official Msp ecta®n Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 190 Blackthorne Rd Property Address Elise Snow Owner Owner's Name information is required for every Marston Mills MA 02648 5-30-13 page. Cityfrown 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-3113 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments p 190 Blackthome Rd Property Address Elise Snow Owner Owner's Name Information is required for every Marston Mills MA 02648 5-30-13 page. Citylrown 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 f3 -1 - 3 >' -a 3 a R MR t5ins•3f13 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 190 Blackthorne Rd Property Address Elise Snow Owner Owner's Name information is required for every Marston Mills MA 02648 5-30-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells N0 P p9 9 12 Estimated depth to I h round water: feett 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: Per past report no G.W. at 12+'. Bottom of leaching at around 4'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 official Msp ection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 190 Blackthome Rd Property Address Elise Snow Owner Owner's Name information is required for every Marston Mills MA 02648 5-30-13 page. Cityrrown 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-3H3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 TOWN OF BARNSTABLE L&CATION / /�'/ar,�Z� (o _ SEWAGE #24F'00 Vr,I-A(.IE - MV —ASSESSOR'S MAP & LO'P_'o,-14( INSTALLER'S NAME&PHONE NO. !?Y�l � M1 SEPTIC TANK C Acr -o UEEACHING FA( rr,? pe 1A1ie'W f7aR (size),NO.OF BEDROOMS SLL&DER%OR OWNER PERMITDATE: f` OMPLIANCE DATE: Cyr 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 fee of ng facili _ Feet Furnished by � � may- ti 1 ANK M � 62Zy-. q 3 6s m - �f�r�J� �f �f f� +. �7es ryNo.'e""�" n� / % Feet--' / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer PUBLIC HEALTH 'DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Ztpprication for Miipooal br5tem Congtruction Permit Application for a Permit to Construct( )Repair( )Upgrade Q'/jAbandon( ) ❑Complete System individual Components Location Address or Lot No. QD �� Owner's Name,Address and Tel.No. Assessor's Map/Parcel Oq7_o3� YVI\� CO \�%fJrj Installer's Name,Address,and Tel.No. 1 Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow c7 '`� gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. 1 Ca pg c-b '1 Description of Soil C0A-P C+P_ S19fI Nature of Repairs or Alterations(Answer when applicab Co --� 4 u 01 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 y is 1 Signed Date 46` "47V Application Approved b aII44e 44Date Application Disapproved for the following reasons Permit No. "' 749 Date Issued ""� `� Z No. — Feet' >"•� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: s PUBLIC HEALTH DIVISION--TOWN OF BARNSTABLE., MASSACHUSETTS ' 01ppIication for Migaal *rgtem Congtructton Permit Application,for a Permit to Construct( )Repair( )Upgrade(','Abandon( ) ❑Complete System ,individual Components Location Address or Lot No. .a P C t 0 rti Owner's Name,Address and Tel.No. 03� N� Assessor's Map/Parcel Ol��� C" \�" Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures \, Design Flow � � gallons per day. Calculated daily flow '`c( gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 91--t l A vol. a Type of S.A.S.)AtA 6a pqr L Description of Soil rvV`eA 1 CCA ��� S19t/b ✓� 77 ./ Nature of Repairs or Alterations(Answer when applicable - -� CCi Date last inspected: Agreement: f, 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 Envi onmental"Code and not to place the system in operation until a Certifi- cate of Compliance has��emis'suedTy t(�iis o t """'- -,,... 1J f ` Signed a Date O' "iqv Application Approved b " Date Application Disapproved for the following reasons ✓ Permit No. Date Issued :-THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance y► THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired ( )Upgraded(`V) Abandoned( )by i -G A �—_ at 0� ��l�c "'t-`no,r�f�J G.u�'�o1l.S �� C '" Y has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction PZ5�WA& dated r' Installer Designer The issuance of this permit ha not be can strua guarantee that the s ill function a/desig a '. Date �^ Inspecto --------------------------------------- No. Fee Vr J THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Mfzpooai *pgte'm Con.5truction hermit,= Permission is hereby granted to Construct a air( ) pgrade )Abandon( rr System located at =a&C W�0:&jl ' 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 a completed within three years of the date oft t. -�- Date: Approved bhy 11609 NOTICE: This Form Is To Be Used'For the Repair Of Failed Septic Systems Only. CER=CATION OF SKETCH AIND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) I, '7 hereby ce:tiiy that the application for disposal works construction permit sinned by me dated concet uns the \ t r property located at meets all of the Following criteria: The failed system is connected to a residential dwelling only. There are no commerciai or business uses associated with,the dwellins. The sail is classified as CLASS I and the percolation rate is less than or equal co 5 minutes per inch. �,iere are no wetlands within 100 feet of the drowsed septic s+sern 6-1-Iffiere are no private wells within 1.40 feet of the proposed septic srse:n f/here is no incense in flow and/or change in use proposed (/-f here are no variances requested or needed. �• fie bonom of the proposed leaching taclin, will not be located less than five feet above the ma.-d.mum adjusted undwater cable elevation. (Adjust the groundwater table using the Frimptor method when applicable} • If the S.A.S. will be located with 2f0 feet of any vegetated wetlands. the bottom of the proposed leaching facility will net be lccated less than founeen(1Y) feet above the m.axamum adiused groundwater table e!aiat on, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) // V B) G.W. Elevation -the M,�-(. High G.W. AdjuT Ment D I RE`+CE E E-I-N-EEN a,and E SIG q-ED : DATE: �� v (Skexh proposed plan of system on backl. a:::c3ith ioldcr..r:c U c 1 r TOWN OF BARNSTABLE j LOCATION SEWAGE VILLAGE ASSESSOR'S MAP &-LOW To e 5 INSTALLER'S NAME&PHONE NO. �►. yt.��.r i SEPTIC TANK C C -LEACHING FAZ� Pe �4A/-Y? riUZa-Z (size) " NO.OF BEDROOMS FOR OWNER PERMITDATE: ,!!�- COMPLIANCE DATE: -�•'' � C 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 fee of ng facili yl— Feet Furnished by i - i I ��, � b I�k 44� THERMCO HOME IMPROVEMENT 7-D HUN -iNd-T' KAVE NUE SOUTH YARMOUTH MA'02664 -DA r. A f. SA .77 - - ll�� c f�. ,. • �, Gave c�y `��d�'1 1A aot--- r'i IN' �a 1p, 54 kg- v 7 y tz 4. 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U7. :L ,.,.. .N ." ^� ,.'»,. �r.•i,n. _ ,.- a ;, ".E'•r _. .. �'1 ..:.. .,..... ..w. .x, ':+.:` .;�: ,i _ ..y v.... ,•„ n .. 3 s r`. s 3 ,.._. :.-,k.. s' �. : '3:� # ukb.t Y. .- .- .....-.t � �� � �� � 'r�-� ^�' t�"v ' � 06-29-2000 03:02PM CENT OST F;REDEPT 5087902M5 P.02 Fire Department retains original application and Issues du/plicate as Permit. �-` �G�J�P/!f2ey7�2e;l�iL�L cf�C:�1(.cG;S�G�2•Gl���/iy - �e�x�m�nCa�C-�i�xe•��cce4-^ ✓GJOGZAkL���� ./ �iuJUd�tLGd/G AWPLICATION and PERMIT HSU for storage tank removal and transportation to approved tank disposal yard in accordance with the provisions �1 of M,G,h.Chapter 148, Section 38A, 527 CMR 9.00, application is hereby made by: Tank Owner Name(please print) _,Jerry Collins x . T OrUr1 f• Y�+A Orpv�4 i Address 190 B1aAthoru Road Marsto s Mills Ma QZLA8 Company Narr.&4e3yanr_Ac3 En3zironmGriaal Co.orIndividuaI PhV Prim Address R Address _ I' 1 r Signatur a ying for permit] I Signature(if appiyng for permit) li Cl Certified Other a IFCI Certified p LSP k Omar ! I� 7TankL~acation 190 Blackthorn Road Marston Millsank Capacity(gallons) 5OO w Substance Last Stored fit Fuel Tank Dimensions(diameter x length) Remarks: Underground Storage Tank Firm transporting wasteAilXd_n_ced Environmental .Stale Lic,f MV5063836100 Hazardous waste manifestk =.P.A.# Approved tank disposal yard James G.Grant Cn. ,Tne Tank yard# _ 008 Typeof inertgas Venting, Tankyard address _hint rntt qt- .,: Fe<adu3-13-e0: HA. i City or Town FOIp# Permit# Date of issue A Date of expiration _ { 02bo Dig safe approval number: zoa 9a._ __ trig Sit Toll Fre T er•AO , Signature J Title of officer granting permit i T kilter removal(s)send Form FP-29OR signed by Locai Fire Dept.to UST Regulatory Compl ante Unit,One Ashburton Place, ;oom 1310,Boston, MA 02106.161 B. I 32(revised 9/W) TOTAL F,n2 YAOT 10N SEWAGE PERMIT NO. $ l"t 2 1-t /i.I-() R S VILLAGE INSTA LLER'S NAME & ADDRESS B U I'L D E R OR OWNER oe foal? DATE PERMIT ISSUED IV 7 DATE COMPLIANCE ISSUED V �v � n _ I � c V 4 p t No......2,.1� ld���. Fss...... �. ...... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........... .TOWN......OF.........BARNSTA ........................................................ _. Appliration for 0W.Vati al Vorkg Tomitrnrtion rrnti# Application is hereby made for a Permit to Construct (A) or Repair ( ) an., Individual Sewage Disposal System at: f Jas er Road--Mars Mills 463 --....... P..- --......... •------•--••.....--•-•................ ........•-•-•----•--••--•-•-•----•..._...... .......•--•--....•---......--------... Location-Address or Lot No: ...11v.............S...........h V.A!ye'-a............................-..._..... Owner Address a ..................................................... ............ Nl.! ............................................................. Installer Address 2 2 0 61 •.,, Type of Building Size Lot.._____..�__________________Sq. feet :.a a Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) ,.. a Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures ..................................................... ---•--------------------------------------------•--...-------•---------.....---•......----•-•-- 110 bdr-. 330 W Design Flow.......... per . per day. Total daily flow...._..._..._._..--_........................gallons. W Septic Tank—Liquid capacity.l 0 0 0gallons Length$_...-6��.._ Width4�...........�Diameter ...... _ Depths -4" x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No......... Diameter......19.1...... Depth below inlet.1.............. Total leaching area...... 40----sq. ft. Z Other Distribution box (X) Dosing tank ( ) Ca a Cod Serve Consultant 8 31 77 Percolation Test Results Performed by •.•-P--- --•-- -- ........... Y date Test Pit No. 1---;..........minutes per inch Depth of Test Pit---- Depth to ground water.______nOTle (Tq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground wate a --•---------••-------------•-•--------.....•••••---•-•--•-•--.......................••-•-••-•--••••-•-......---•-..........••_. .. . ...... O Description of Soil See...at Plan-_.. ------------------ ----RaSERX---- s� V ...................•-•--•-•-----------------•--•--------...-••-------•---•-•-----•---•-•••----•-•----•......--•--•••----••---•-•-----•----......-•----•......_........-- <D......-----F:...---•--.. DAYLOR W -•---•-----•------------------------------•-•-••-•-•-----•--------••-•-•---.........------•-----••---••----•-•-------•------....------............---•-•.............. --A p Wd:23741..... cn U -Nature of Repairs or Alterations—Answer when applicable---------------------------------------------------------------- _.so ...._......4i0_Q U IJ� �`�S . -•-•-----•-----••...................•-------•-•---------..............._......--•-•-............----•---...-•-------------....--•----•-------.........•----------_. S/ . Agreement: L The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in acco the provisions of TITT 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by. the board of health. ne ..•. . ....... --­..'-•----------------------------------------------------- ---•---•--•-•-------•---- Date Application Approved BY ----------- Date Application Disapproved for the following reasons-------------------------•-------------------•----------••----------------•----------•----------•-------••••--•-- -•-------•---------------•-•-•----•--------------------------------------•-•-----..............----••-•--••-------------•-•-•--------------------------------------------------------------•------------ Date PermitNo......................................................... Issued•....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS ` .,,n BOARD OF HEALTH ................IA'Z�"`-�/...OF..................................................................................... Tntifiratr of TuntpfiFanrr THIS IS TO CERTIFY That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by �._....... c1—' ./-�--��------•----------------- r.1 _ Installer at..�'1'... ��� -��s�'�� ��?.:.....................M..!--- --------------------------- has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dated_............................_.................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION -SATISFACTORY. DATE......�4� ............... Inspector... ------------------•--------•---------•----------------- �. FEs...... .................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......................TOWN......OF........BARNS TABLE................................................. Appliration for Bi-spas ai Works Tonstrnrtiun i1trutit Application is hereby made for a Permit to Construct (fit.) or Repair ( ) an Individual Sewage Disposal System at: •Jasper•._Road�-Marstons Mills 463 ......... ................................................ --------.....---•--.....--•-••..................... Location-Address / or Lot No. A•<+ -!/ .1+�? :t'�?_P..!?.i,n --------•--- ----- -• � �l_S'_7.....3 `� :!3!� ....................................... Owner Address W •.............s .-•c3 0 ?1 .... ��/?!!.R. a ------------- .. .....------......-----•----•-----•---...... Installer Address 22 ,061 Q Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) p4 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) aOther fixtures ............................................................. Lra Design Flow..-•----:110_____•_-__.....1000 gallons per,-���per6 day. Total L11v flow.........................................5.�_al�o s. WSeptic Tank—Liquid capacity............gallons Length............... Width..............._ Diameter-----.._........ Depth...•. ......... x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area.._..•..............sq. ft. Seepage Pit No..._..1............ Diameter.....10.".......'Depth below inlet.6................ Total leaching area... 340............ sq. ft. Z Other Distribution box (X ) Dosingtank ( ) C'a a Cod SurveyConsultant 8/31/77 Percolation Test Results Performed by P •---•--••---- ......................••-- date .._.....------•.- aTest Pit No. 1..z...._.._.__minutes per inch Depth of Test pit...12............ Depth to ground water.......nOnE'...... Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground wa 4�tR•pf.Mgs O Description of Soil. See---attaehed....?lan"-.... ..........••-•••-------••--••••---•---•-•--•-•----••-••....•... f2E38�ft �y�N V _ .................................................................. ............. �............E............• W •-----------------t........................................................................................................•............................ `� --•-DAYLOR p', U Nature of Repairs or Alterations—Answer when applicable............................................................. a..�Go.23741 . -------•---•---•--......---•-•-------------•....--•---......_..............................---------------------•--......--••••-•-•-••.••. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in acc ► e ith the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. ned .. `...........C `r r.:..................................................... Dat Application Approved BY "' „ � ` j .................. ''-« �" ----------- Date Application Disapproved for the following reasons---- --------------------------------------------------------------•---...•...-----------------------------••-- --------•-----....--•--------•---•----------•----------------------------------------------•---------------•...•---•--•--•-•-•••--•--•••-•-----•----••-•-•-•---••••-•---•....••••...••••--•--•-.....---- Date PermitNo......................................................... Issued........................................................ Date THE.,,COMMONWEALTH OF MASSACHUSETTS BOARD .OF HEALTH 1 .. 2.r/.1,/..J.....O F..........................:............................... ................ (9rrtifiratr of fauntph anrr THIS IS TO CERTIFY That the Individual Sewage Disposal System constructed (X or Repaired ( ) by---------------------------------------------- ......... -6..................................................................................................... ............... Installer .. =' A �p .Lit ..............•----- 3 .............................................................................. has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dated----------------------- ........................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM LL FUNCTIO"TISFA�jCTOORY. DATE....... ..-9::�-/............ ./... -j............ Inspector...............................0.................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEA61H .................l... ✓.....OF............. Q --L, '-Ql ...:..ei...................... N T.... FEE.....`......'...... Disposal Vark.5 Tnnotrnrtinn rrntit Permissionis hereby granted............... •••..•••----••••-•---•..._..•--•---•---•--•-•••••••--••-....._....---•..............-----........... to Construct ()1_ ) or Repair ( ) an Individual Sewage Disposal System atNo W-r - { ?,hd ....... L3: = ' --------------------------••-•............••-••-••--.. . ........... Street ''// as shown on the application for Disposal Works Construction Permit N ''.._..._.420.7`._ Dated_.._...._._9C�L�77....._. Board of Health DATE----------------�1--a 7.......---•----------•---------------••--- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS f 1 • SOIL L08 w1 /39 • �Xh1!�Ui.p\Vnuv-�Kariia..ui�rwvi,�w/il✓�.t—� .� L.�o oD� rl�.v L�• 2•;.PEASTONE LOAM 8 FILL— 12"MAX. sv b r r^ DIST +II'•°D •MeI N.e ,T4!'C. I. 6 0 00BOX ° . 24 1000— GAL_ 0 M OOO I 0 Li GAL. PRECAST OR 0 ° °I I+ D'4•- BLOCK ° °° I L S TAN1K 6 1 ;+w 0 SEEPAGE PIT 0° °o /3✓i w e or s eo 0 0 I O t t + ° • o — — — — — b p of 20' MINIMUM Io°°°• ,° .� +�- _ � I -FOUNDATION I �r /Z7. I %t WASHED STONE ---� . I i✓o U3.o•fc+.�. .► �C6 Qy CezTi� �. > 7'.�i� l SCALE: 1"= 5' �7.Ce�G?c.v.�'�" S.�cJ4✓n/ /�'A'+C6'�0../�.¢r5 r J iisr/DcrG Zn..�.y�i✓. Goc.n> a.�-ar✓ r4r�!. -scram_ ,ri c�aLL� 10 Paue. RAYQ s �v,e=,vl ©:� .�r�Gb�3, �,97'3-��;� Gonll�o•tM S TEST BY : ,✓�, ,5 ,6 t,.T, tow.." s6w_vo s,, TOWN INSPECTOR A�►csL `s�+•'c'e"a?'� . BACKHOE OPERATOR : a -r �Pve-�ai S re�arb d�✓�<T u�sr yo�. TEST MADE ON tN OF a ' �'�<�OC off' Q ••� , �.y ROBERT G £� ROBfiaT 6N+s _ F. M GAYLOR fl, DA7;IOf€ � 23T41,p ►b, T � No.,4Q108 C '� F Fi0 . e ,. URV�yo 17 • V - � t I � ti . � t37,3. � , ., � � '. E N. tT � s ,� Xie 6 9 - � ' . g NItj60 Elk i -3 c•� ELEVATION SCHEDULE PROPOSED 81YL PLAa 1. INV. AT FOUNDATION = /34.SL • _ 2. 1 NV. INTO SEPTIC TANK - t3c,.37 - IN 3. 1 NV.. OUT OF SEPTIC TANK - �+ 4. INV. INTO DISTRIBUTION BOX 0 SCALE: 1"=eo ' 19> 7 C—SG7� 5. 1 NV. OUT OF DISTRIBUTION BOX ., �_ t 13�, Grp CAPE COS SURVEY CONSULTANTS 6. INV INTO SEEPAGE PIT - ROUTE 132 7 ;BOTTOM OF PIT _ 12$•So HYANNIS,MASS. t A DIVISION BOSTON SURVEY CONSULTANTBr INC. G _ I $.So -+' 8. �OTTOM OF* STONE LAYER - •v