HomeMy WebLinkAbout0291 BLACKTHORN ROAD - Health 291 BLACKTHORN ROAD, MARSTONS MILLS
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
c DEPARTMENT OF ENVIRON- ENTAL PROTECTION
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TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address:</ o��:� 30 vZ�
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Owner's Nam
Owner's Add %
na
Date of Inspection: ;
-E'::
Name of Inspect (plea a print) �"V ° I�t rI `= `-
Company Nam
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Mailing Address: 6C!
AM
GAS` w
Telephone Number: ���g- 7"7I- 2aq
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CERTIFICATION STATEMENT c-n rr'•
I certify that I have personally inspected the sewage disposal system at this address and that the Id
formationrepoxed
below is true, accurate and complete as of the time of the inspection. The inspection was perfor 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
Needs Further Evaluation by the Local Approving Authority
ils
Inspector's Signature: Date: d'�/6
The system inspector shall submL 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 shad 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.
Notes and Comments
t
****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 1
Page 2 of 11 (.
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS 1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 09 v =
Owne 9
Date o nspection:_� U
Inspection Summary: Check A,B,C;D or E./ALWAYS complete all'of Section D
A. s System Passes:
V I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist.Any failure criteria.not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired. The system, upon completion of the replacement or repair;as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N.ND)in the for the following statements. If"not determined' please
explain.
The septic tank is metal and.over 20 years old* or the septic tank(whether metal or not).is structurally:
unsound, exhibits substantial infiltration.or exfiltration or tank failure is imminent.Systeml will pass inspection if the
existing tank is replaced with•a_complying septic tank as approved by the.Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain: _.
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 requiredpumping.m•o_e 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:
2
Page 3 of I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: � � C
Owne
Date spection
C. Further.Evaluation is Required by the Board.of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier, if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has:a septic tank and soil absorption.system (SAS)and the SAS is within.100 feet of
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 DAP certified laboratory, for coliform .
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to:or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
3
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Page 4 of 11
OFFICIAL INSPECTION FORM—:NOT FOR VOLUNTARYASSESSMENTS '
SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: Qp / 1�L z
At,e
Owner:
Date of pection: � J-
D. System Failur Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No/
t/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
,1 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
_ Required pumping more than 4 times in the last year NOT due to clogged_ or obstructed pipe(s).Number '
J of times pumped
_ V 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.
_ ✓ Anyportion of a cesspool or privy is within.a Zone I of a.public.well.
_ Any portion of a cesspool cr privy is within.50 feet of a.private water supply well.
Any portion of a cesspool cr privy is.less than 100 feet.but greater than 50 feet.from:a private water
supply well with no acceptable water quality analysis. (This system passes if the well water analysis;
performed at a DEP certified.laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the:presence of ammonia
nitrogen and nitrate nitrogen is equal 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.)
(Yes/No)The system fails. I have determined that one or more of the above failure criteria.exist as
described in 310 CMR 15:303,therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd•
You must indicate either"yes"or"no"to each of the following:
(The following,criteria apply to large systems in addition to the criteria above)
yes . no
the system is.within 400 feet- 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—I WPA)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 31.0 CMR
15.304.The system owner should contact the appropriate regional office of the Department.
1
Paee 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: .
Owne
Date o spectio
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
t/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 ?
7Have
large volumes of water been introduced to the system re,,ently 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?
V — Were all system components,excluding the SAS, located on site?
V '_ Were the septic tank-manholes uncovered, opened,and the in-
_erior of the tank inspected for the condition
of the b ffles 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 owne-)provided with information on the proper
maintenance of subsurface sewage disposal systems
The size and loc2tion of the Soil Absorption System (SAS)on the site has been determined based on:
Yes no
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(3)(b)]
5
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Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM:INFORMATION
Property Address: QX-1 7u
Date of. s ection:
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): dumber of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203 (for example: 11.0 gpd x#of bedrooms):
Number of current residents:
Does residence have a garbage grinder(yes or no):
Is laundry on a separate sewage system,,' s or no);rt b.[if yes separate inspection.required]
Laundry system inspected(ye or no):_
Seasonal use: (yes or no):
Water meter readings, if a ailable(last2 years usage(gpd)): 0
Sump pump(yes or not (/ �2�'�ze�� ..\
Last date of occupancy: ,
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgfi;rtc.):
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:
Was system pumped as part of the it slYction(yes or no):_ZV6' '' 4—
If yes, volume pumped: gallons--How was quantity pumped determined?
Reason br pumping:
TY E OF SYSTEM
Septic tank,distribution box, soil absorption system
_Single cesspool
_Overflow cesspool
_Privy
_Shared system (yes or no)(if yes,attach previous inspection records, if any)
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system.owner)
Tight tank _Attach a copy of the.DEP approval
_.Other(describe):
p roximate age of all con one s,date 'ristalle f known)and urce of information:
r p
Were sewage odors detected when arriving at the site(yes or noV//
6
Page 7 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM.INFORMATION(continued)
It
Property Address: d (�
c/
Owner:
Date of I ection: (�
BUILDING SEWER(locate on site pla�
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: (locate on site plan)
Depth below grade:
Material of construction: concrete_metal_fiberglass polyethylene
—other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions:
Sludge depth: e?, // Al
Distance from top of sludge to bottom of outlet tee or baffle: 3
Scum thickness:
Distance from top of scum to top of outlet tee or baffle: L
Distance from bottom of scum to bottom of tlet tee or baffle: J
How were dimensions determined:
Comments(on pumping recommend ions, ml t and outlet tee or baffle condition, structural integrity, liquid levels
related to outlet invert, evi a ce of leakage,etc.):
f
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 11
OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECT11W FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
9 ft
�
Owner: '
Date of� ection.
TIGHT or HOLDING TANK:I,1 (eank 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: gallor_s/day
Alarm present.(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches, etc.):
DISTRIBUTION BOX: (if pre.sznt must be opened)(locate on site plan)
Depth of liquid level above outlet invc:l*
Comments(note if box is level and distri tion to outletsal, any evidence of solids carryover, any evidence of
J- l a4age into or out of bo , et .): �oglt ,
/177
PUMP CHAMBER:/ (locate on sate 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.):
R
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: Ae
Owne . eiP�
Date of pection: J
27-
SOIL ABSORPTION SYSTEM (SAS):Lzoocate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching.pits,number:_
leaching chambers,number:
1 Ching 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): _ .. >
CESSPOOLS (cesspool must b'e pumped as part of inspection)(locate on site plan)
Number a/dconfiguration:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of.groundwater inflow(yes or no):
Comments(note condition of soil, signs of hydraulic failure,level of pending, condition of vegetation,etc.):
PRIVY;�W(locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil, signs of hydraulic failure, level of p(mding,condition of vegetation, etc.):
9
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Page 10 of l l
OFFICIAL INSPECTION FORM.—NOT FOR:VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner:
Date of pection: /� (0 Q
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 =00 feet.Locate where public water supply enters'the building.
��D
d
Lillalkn
64
c
�� 4C bc��dC1t1
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Page ]] of l l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATIO�N(continued)
Property ddress:
Owner 90
Date of ection Q
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 2 ?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:
Observed site (abutting prop erty/6bservation hole.within 150 feet cf SAS)
Checked with local Board of Health-explain:
� Checked with.local excavators, installers-(attach documentation)
V Accessed USGS database-explain:
You must describe how you established the high ground water elevation
j <
11
Per-nit Number: Date:_
Completed by: �`
HIGH 3ROUND-WATER LEVEL COMPUTATION
`Site Location: Lot No.
9
Owner: f Z �/'C�°. Address:
Contractor: �/�� 11 C,I/dPv Address tl�<�� �� jQj/y,
Notes:
STEP 1 Measure depth tow table
water
to nearest 1/10 ft. _._........... .................................................. .... .Date, •::,�.
month/day/year YM."
STEP 2 Using Water-Level Range Zone
and Index Well Map i_;cate site and determine:
Appropriate index well............................ `Y.•..... �� j ie
OWater-level range _�T)e ....... .............................:......... ..
STEP 3 Using monthly report. Current
Water Resources,Cond=ions' _=
determine cur.-e.nt.depth to
water level for index ;all........................... ���J� `C ✓S r ?'
month/Year
STEP 4 Table of W el Adjustments
Using Water- er _ --
for index well (STEP 2,A), current depth
to water level for index,well (STEP 3),
and water-level zone (STEP 2B)
determine water-level zzjustment
STEP 5 Estimate depth
P.h to high water
b subtracting l ,sFS4yu ,:s_y✓
Y ling the
adjustment (STEP 4)
from measures depth to water
level at site (S—EP 1) -- .........................
............................._.....
i
}
Figure 13.--Reproducible computation form. m;
+ 3'39
boy
__.............
,..__ ...__.__.., __. __..._.� . , ..�___..... , , ._•_..
wo
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I
TOWN OF BARNSTABLE /
1,(}C4TION �j �;lc.��` fQ SEWAGE #
VILT-AGE ot64 b, ASSESSOR'S MAP & LOT_0 7-01;—old
INSTALLER'S NAME&PHONE NO. ROW-5 C yC dn'A n,14 ietf C/'71-0 7.'
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) 3)�,Cl 14AA-46N (size) 377'5C- 1/f
NO.OF BEDROOMS
BUILDER OR OWNER
PERMIT DATE: _COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
A2 Y1
43
ear
k7r 3Y
.?Z Y/
oa
3
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TOWN OF BA.RNSTABLE
1C 'TION. �nl/�C�I:�C ,Gll�1r/h 9�5 0 � SEWAGE # ��//
LLAGE ASSESSOR'S MAP & LO
T�1/�PE�iTOIQ S�NAME&PHONE NO c�• /
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) '(size)
NO. OF BEDROOMS \�
BUILDER OR OWNER
e v
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
0.
40
—ronK
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No. 3 FEE
COMMONWEALTH OF MASSACHUSETTS'
Board of Health, �1—✓bt0`"� ,MA.
APPLICATION [OR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct(v�<,pair( ) Upgrade( ) Abandon( ) - ❑Complete System (b�vidual Components
Location a- 1 J 1-IQG j<T HoR N 0Z '/ Owner's Name ;TAGfC-F �i1��, �i'("Z��✓Z�L�
Map/Parcel# 7 Address
Lot# Telephone#
Installer's Name Designer's Name Ygq,u k,, S,-j&v Pt
Address Address 1/0 Z y v1 7.S r,- R roo
Telephone# Telephone# L0,8-00 S
Type of Building Lot Size 3 ci3s 1/0 ± sq.ft.
Dwelling-No.of Bedrooms Garbage grinder (VO
Other-Type of Building No.of persons Showers ( ),Cafeteria ( )
Other Fixtures
Design Flow (min.required) 3 3 gpd Calculated design flow 38 &PD Design flow provided 3 g gpd
Plan: Date -7— )S- cl`7 Number of sheets Revision Date
Title S r t $2 t.n�{Q_ p)s4 J1J
Description of Soil(s) J,4 10 q �y
Soil Evaluator Form No. Name of Soil Evaluator 43ruce CT. N'IUr Date of Evaluation �—3' / /
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
In coons � 7
No. 9` J ?D t -"�' ' FEE
J Board of Health, `P�h S1�w``Q MA.
APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION ARMIT
Application for a Permit to Construct(ur-4Repair( ) Upgrade( Abandon( - ❑Complete System individual Components
t Location :2T 13LAc kT NOR N 1/-2 Owner's Name -5AcC-t 4hDc, r,T26e&41 J7
Map/Parcel# / 7 Address
Lot# 09 Telephone#
Installer's Name Designer's Name YA A-V,F Sv 2 Ve &AiS v 17A+v7s
Address Address "IO jTS ,�,4 1��5 4✓ 6RG+A
Telephone# Telephone# 00 Sj
Type of Building Lot Size 3�,,�410 ±± sq.ft.
Dwelling-No.of Bedrooms 3 Garbage grinder VVO
Other-Type of Building No.of persons Showers ( ),Cafeteria ( )
Other Fixtures
Design Flow (min.required) 3 f; gpd Calculated design flow 349 6'170 Design flow provided 3 g gpd
Plan: Date 7- ty I S- cY / Number of sheets Revision Date
Title S + + S-e - t�
Description of Soil(s) S*-e :`V —f q
Soil Evaluator Form No. Name of Soil Evaluator 3ryc a(?. /n'lu/��n' Date of Evaluation /
s` DESCRIPTION OF REPAIRS OR ALTERATIONS ~
k
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
-Signed Date
Ins ctions
No. / / �V FEE
C®MMONWEALT14 ®F MASSAC14US ETTS
Board of Health, 3 a-J''n STu�1C' ' MA.
CERTIFICATE OF COMPLIANCE
" Description of Work: ❑Individual Component(s) �mplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed (t)!'Repaired ( ),Upgraded ( ),Abandoned ( )
by:
at IIAGkTIfyR R
has been installed in accordance with the provisions.of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. 9 7"3 2O, dated ,73- 9 Approved Design Flow 3 (gpd)
Installer �7�
Designer: \/,ANke eS,/kiet�er/"+ v)TArinsspector: Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. FEE IDU
COMMONWEALTH Of MASSACHUSETTS
Board of Health, ?-M:>-/V1 Sf c,6 l-Z • , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at !�)a.c kG—t Ho IR N U r917 as described in the application for
Disposal System Construction Permit No. 7 3 70 ,dated 7-�3 _ 5;�2
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
Form 1255 Rev.5/96 A.M.Sulkin Co.Boston,MA Date M i - l t Board of Health �-A
,
r y J + r.
Town of Barnstable P a
Department of Health,Safety, and Environmental Services
dt n�'oyl
Public Health Division Date
� 367 Main Street,Hyannis MA 02601
SAMgr BtA q t�o i
A.019, Time Date Scheduled I Time 10 Fee Pd,
Soil Suitability Assessment for Sewage Disposal
1MU/�,�y -� Witnessed By: S_ e✓/�, 1�c�'^'^� --
Performed By: 1J�
LOCATION & GENERAL INFORMATIONI
cA
Location Address��� �L („ i p � _(, -
Owner's Name 31egC,
Address
Assessor's Map/Parcel; d17 J1a,—t t Lurt' 11 r4• Engineer's Name yA w
k e-e S Q,wp
NEW CONSTRUCTION ✓ REPAIR Telephone M 00
Land Use _ Lt,- r✓te_�• Slopes(%) /' Surface Stones
Distances from: Open Water Body ft Possible Wet Area — ft Drinking Water Well ft
Drainage Way 40or ft Property Line — ft Other ft
SKETCH: (Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes)
�P, i3'
I
n
► toot
j3 Trfo�1� �3
6 0;kll kk St 6J R,Q A� a
Parent material(geologic) [°u4 Q VAR' Depth to Bedrock
P �
Depth to Groundwater: Standing Water in Hole:
})ONg I Weeping from Pit Face
Estimated Seasonal High Groundwater
DETERMINATION FOR SEASONAL HIGH WATER TABLE
Method Used: In
Depth Observed standing in obs.hole: in. Depth to soil mottles:
Depth to weeping from side of ohs.hole: in. Groundwater Adjustment ft.
Index Well q Reading Date: index a level Adj.factor Adj.Groundwater bevel _
PERCOLATION TEST DateiTMT Time 10
Observation Time at 9"
Hole#
Depth of Perc 3 I�a / Time at 6"
Start Pre-soak Time Q 10'y�t/L Time
(9%6")
End Pre-soak /0• A)i Oa o 0•,Y7
Rate Min./Inch e
Site Suitability Assessment: Site Passed ✓ Site Failed: Additional Testing Needed(YN)
Original: Public Health Division Observation Hole Data To Be Completed on Back—�
Copy: Applicant
DEEP OBSERVATION HOLE LOG Hole # .L
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling Structure,Stones, Boulderes.
%Graveh
Q 1-G 10 yA 3-1
ti
In-eblum I Rr'o-$
ati "s�, ► r &Rwe I C, L
mei'�,t
po t
DEEP OBSERVATION HOLE LOG Hole # a
Depth from Soil Horizon Soil'Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling Structure,Stones,Boulderes. .
o
Gravell
Q
CA ID q-6
C I --&vA 10yR v_8
�
��'►yy c a �t��N� � .�_y
DEEP OBSERVATION HOLE LOG Hole #
Depth from Soil Ilorizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) ,_ Mottling Structure,Stones,Boulderes.
%
DEEP OBSERVATION HOLE LOG Hole #
Depth from Soil I lorizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes.
%
DEEP 0BSERVH T I0N ni.L: LOG Ho; C 1
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes,
% raych
ri
CATCH MARSTONS MILLS yV
BA WATER PIPE 5��y
�4
PLAN REF.' 38534E SH.2 4`
i & 42083 A2 LANE
RES. ZONE.' "RF" RACE
I
HSE. �Q 9
BLACKTHORN
LOCUS
\ RECREA TION
��
\ EASEMENT LOCUS MAP
98. 5 / �1�PROPOSED � W( �� L "v� �'
O 6's pp- BENCHMARK
/ GARA CATCH
i T L TOP OF TAGBOLT
i / p PROPOSED -�� � BASIN LEV.=100.0(ASSUMED
3 BEDROOM
D WELLING 0
ol
s / ° 98.5IQ
ol
l
I ` �� / ti ii PROJEC T L OCA TION
' 6�jQ TP#1 ASSESSORS LOT 12-11
Jy �' BLACKTHORN ROAD
/ Ti / ��� MARSTONS MILLS, MA.
LOT 11A x � APPLICANT'
�s A.M. 4 7/12-11 A CK & LINDA FITZGE'RALD
6'Op AREA=39,540_:�-S.F. /o0�
OPEN SPACE YA NKEE SUR�E Y' CONSUL TAN TS
/ ti�� A.M. 47/96-1 P. O. BOX 265
A.M. 32/17 `•i / �� �� UNIT 5, 4 0B /ND US TR Y ROAD
Y MA. 02648
�OF ,A �y� OF MA RS TONS MlL L S,
�► c.B PH. (508)428-0055 - FA X(508)420-555 3
t . G. e MERE► SCALE.' »
=
MURP�Y �� � g 1 30 �JFDATE- 7/18/97
NO.749
REV.' REV.'
A
JOB NO. 51349 FSHEE 1 OF 2
:i
100' 4
TOP OF FOUNDATION k
20' MIN.
10' MIN.
CONCRETE COVERS 4" SCHEDULE 40 P V.C.
EL. = 98.05' MIN. PITCH 1/8 PER FT. 2"LA YER OF
1/8„_I/2»
6" MAX / / CONCRETE COVER WASHED STONE
EL. 98.25
4" CAST IRON PIPE i
(OR EQ UAL) MINIMUM
PITCH 1/4 PER FT CLEAN SAND 9"
FLOW LINE 10 15' EL=96.0 MIN.
INVERT 1 .10 _
97' MIN. 14" °ss0 0 0
EL.--- IN �L�E
.0 ° o00 o o--- GAS 6,� VEL o 0 0° o o °o
INVERT BAFFLE EL = 96.50' INVERT INVERT °° °° ° 'oo o —
EL.= 96. 75' --- — 96 25' ° ° ° o ° ° EL.— 94.5
-- EL.---=-- EL.=96 -- 4' 4'
xx (TO BE PLACED ON FIRM BASE) DISTRIBUTION INVERT
MECHANICALLY COMPACTED OR 6' OF STONE BOX EL.__ 95.5_
11'x38'x1'
1500 --GALLONS
TO BE WATER TESTED TRENCH FORMATION
SEPTIC TANK IF MORE THAN ONE OUTLET SOIL ABSORPTION L
PLACE ON 6" STONE
3/4" TO 1—I/2"
PROFILE OF WASHED STONE S YST�11�1 (SA S�
S�' ���' IS P O S�L S YS T�' BOTTOM OF TEST HOLE OR USGS PROBABLE WATER TABLE ELEV. =_86
NOT TO SCALE NO OBSERVED WATER TABLE (713197) ELEV. =--86—
OBSER VA TION HOLE I ELEV= 98
PERCOLATION RATE MINI INCH AT _44'- INCHES OBSERVATION HOLE 2 ELEV= 96 --
�`' DEPTH HORIZ TEXTURE COLOR MOTT. OTHER DEPTH HORIZ TEXTURE COLOR MOTT. OTHER
0"-6" A SANDY LOAM I0YR3-1 0"-6" A SANDY LOAM 10YR3-1
6"-24" B LOAMY SAND I0YR4-6 6"-24" B LOAMY SAND I0YR4-6
GENERAL NOTES 24"-52" Cl MEDIUM SAND I0YR6-8 4"-52" Cl MEDIUM SAND I0YR6-8
AND GRAVEL PERC. AND GRAVEL
52"-144 'C2 MEDIUM SAND I0YR7-4 52"-144 MEDIUM SAND I0YR7-4
1) ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO D.E.P.
TITLE 5 AND THE TO WN OF _BARNSTABLE RULES AND NO WATER NO WATER
REGULATIONS FOR THE SUBSURFACE DISPOSAL OF SEWAGE.
2) ONE COVER ON SEPTIC TANK SHALL BE BROUGHT TO SOIL TEST
WITHIN 6" OF FINISHED GRADE, OTHERS WITHIN 12" DATE OF SOIL TEST 713197 SOIL TEST DONE BY BRUCE G. MURPHY , R.S.
3) ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE CAPABLE OF
WITHSTANDING H-10 LOADING UNLESS THEY ARE UNDER OR WITHIN WITNESSED B Y: JERRY DUNNING
10 FT. OF DRIVES OR PARKING AREAS N--20 LOADING SHALL BE DESIGN CALCULA TIONS.'
USED UNDER OR WITHIN 10 FT. OF DRIVES OR PARKING AREAS.
4) ANY MASONARY UNITS USED TO BRING CO VERS TO GRADE SHALL NUMBER OF BEDROOMS . . . 3
BE MORTERED IN PLACE. GARBAGE DISPOSAL . . . . . . . . . NO
5) NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH END LOAD 5 INFILTRATORS WITH TOTAL ESTIMATED FLOW
DEEDED OR ZONING REGULATIONS. OWNER/APPLICANT IS TO 4' STONE SIDES AND ENDS ( 110--GAL./BR./DAY x 1--- BR.) 330 GAL/DA Y
OBTAIN SUCH DETERMINATION FROM APPROPRIATE AUTHORITY. REQUIRED SEPTIC TANK CAPACITY 1500 GAL
6) UTILITIES SHOWN ARE APPROXIMATE ONLY, EXCA VA TION CONTRACTOR 11 X 38'X 1'
LS TO CALL 'DIG- SAFE" AT 1-800-322-4844 AT LEAST 72 HOURS SOIL CLASSIFICATION . . . . . . . . 1
PRIOR TO COMMENCING WORK ON SITE. DESIGN PERCOLATION RATE . . . . . < 5 MIN./IN.
7) CONTRACTOR IS TO VERIFY GRADES AND ELEVATIONS AS WELL AS EFFLUENT LOADING RATE . 74 GAL/DAY/S.F.
SITE CONDITIONS PRIOR TO COMMENCING WORK ON SITE. LEACHING CAPACITY (AREA X RATE) 381 GAL/DA Y
8) PARCEL IS IN FLOOD ZONE --"C" RESERVE LEACHING CAPACITY . 381 GAL/DAY
9) LOT IS SHOWN ON ASSESSORS MAP _47_ AS PARCEL — 12-11_ (38x11x. 74)f(38f38+11f11x. 74)
SHEET 2 OF 2 JOB NUMBER _ 51349-------
\ r
CATCH MARSTONS MILLS
BASIN ,-�� WATER PIPE
�J
PLAN REF.' 38534E SH.2/ ��4
& 42083 A2 LANE
RES. ZONE.' "RF" RACE
HSE. 99.0
NCO y O
I� 111 ROAD
�/ BLA
e CKTHORN
LOCUS
RECREA TION -
�� cods?
\ EASEMENT LOCUS MAP
� W�
98. 5 0 \ s
\ / / �1�PROPOSED Q ��O . --��'� `P'
\ / GARAGE �� �' �`S�. L`90 CATCH BENCHMARK.
BASIN TOP OF TAGBOLT
PROPOSED --�� �6 LEV.=100.0'(ASSUMED)
3 BEDROOM
D WELLING 0
lb' ; ti g
S
/ 7 \\ / lb
T# p j ii PROJEC T L 0CA TION
ASSESSORS LOT 12-11
00. N� BLACKTHORN ROAD
MARSTONS MILLS, MA.
LOT 11A �� APPLICANT.'
�s A.M. 4 7112-11 /�ti ��� �� JACK & LINDA FITZGERALD
6'OO AREA=39,5404-S.F. /00�
OPEN SPACE YA NKEE SUR VE Y CONSUL TA N TS
A.M. 32117 / �ti �� A.M. 47196-1 P. O. BOX 265
UNIT 5, 408 INDUSTRY ROAD
SN OF
OF � MARS TONS MILLS, MA. 02648
PH. (508)428—0055 — FA X(508)420—555J
PAULiL v<?
BRUCE RIThOEW
G No 32�8 13= SCALE: 1"=30' DA TE.' 7118197
MU
Rpw a
No,749 A�FESS�D�P~
k �9No suRv��� i REV._ REV.'
JOB NO. 51349 SHEET 1 OF 2
EL. = 100'_
TOP OF FO UNDATION °
20' MIN.
10' M. CONCRETE CO VERSA 4" SCHEDULE 40 P V.C.
' MIN. PITCH 1/8 PER FT. 2'LA YER OF
EL.= 98.25'
CONCRETE COVER WASHED STONE
s MAX i i �' EL. =96 25
4" CAST IRON PIPE
POT H1/4 EUAL' MINIMUM' PER FT
F
-CLEAN SAND 9"
FLOW LINE 10 MIN.
15' EL=96.0
INVERT 1 10"
rLIIN. 14 ° 00 o
EL.= 97 --- IN 6" S LEVEL ° °o°
GAS ° o 0
UM
INVERT BAFFLE EL = 96.50' INVERT INVERT o°° o° ° 0° EL.=94.5
EL.= 96. 75' EL.= 96.25' D EL._�j96 --ER 4' 4' ---
(TO BE PLACED ON FIRM BASE) DISTRIBUTION @� INV Tl� T
MECHANICALLY COMPACTED OR 6" OF STONE BOX EL.
11'x38'x1'
1500 _—GALLONS TO BE WATER TESTED Lr)
TRENCH FORMATION
SEPTIC TALK IF MORE THAN ONE OUTLET
PLACE ON 6" STONE 3/4" TO 1-1/2" SOIL ABSORPTION
PROFILE
ROFIT E OF
WASHED STONE S YSTEM (SAS) +
SEWAGE WAGE DISPOSAL SYSTEM BOTTOM OF TEST HOLE OR VSGS PROBABLE WATER TABLE ELEV. =_8_16___
NOT TO SCALE NO OBSERVED WATER TABLE (713197) ELEV. = 86_
OBSERVATION HOLE 1 ELEV=_98_
PERCOLATION RATE <5 — MIN./ INCH AT _4 4" INCHES OBSER VATION HOLE 2 ELEV.= 98
DEPTH HORIZ TEXTURE COLOR MOTT. OTHER DEPTH HORIZ TEXTURE COLOR MOTT. OTHER
0"-6" A SANDY LOAM I0YR3-1 0"-6" A SANDY LOAM I0YR3-1
6"-24" B LOAMY SAND 10 YR4—6 6"-24" B LOAMY SAND 10 YR4—6
GENERAL NO TES 24"-52" Cl MEDIUM SAND 10YR6-8 4"-52" Cl MEDIUM SAND 10YR6-8
AND GRAVEL PERC. AND GRAVEL
52"-144 'C2 MEDIUM SAND I0YR7-4 52"-144' MEDIUM SAND I0YR7-4
1) ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO D.E.P.
TITLE 5 AND THE TOWN OF _BARNSTABLE____ RULES AND NO WATER NO WATER
REGULATIONS FOR THE SUBSURFACE DISPOSAL OF SEWAGE.
2) ONE COVER ON SEPTIC TANK SHALL BE BROUGHT TO SOIL TEST
WITHIN 6" OF FINISHED GRADE, OTHERS WITHIN 12" DATE OF SOIL TEST 71/97 SOIL TEST DONE BY BRUCE G. MURPHY , R.S.
3) ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE CAPABLE OF
WITHSTANDING H-10 LOADING UNLESS THEY ARE UNDER OR WITHIN WITNESSED BY: JERRY DUNNING.
10 FT. OF DRIVES OR PARKING AREAS. H—20 LOADING SHALL BE DESIGN� CA L C ULA TIONS.'
USED UJVUE1e OR WITHIN 10 FT. OF DRIVES" OR PARKING AREAS
4) ANY MASONARY UNITS USED TO BRING COVERS TO GRADE SHALL NUMBER OF BEDROOMS . . . . . 3
BE MORTERED IN PLACE. GARBAGE DISPOSAL . . . . . . . . NO
5) NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH END LOAD 5 INFILTRATORS WITH TOTAL ESTIMATED FLOW
DEEDED OR ZONING REGULATIONS. OWNER/APPLICANT IS TO ( 110—_GAL./BR./DAY x 3___ BR.) 330 GAL/DA Y
OBTAIN SUCH DETERMINATION FROM APPROPRIATE AUTHORITY. 4' STONE SIDES AND ENDS —
11'X 38 X I' REQUIRED SEPTIC TANK CAPACITY 1500 GAL
6) UTILITIES SHOWN ARE APPROXIMATE ONLY, EXCAVATION CONTRACTOR
IS TO CALL 'DIG— SAFE" AT 1-800-322-4844 AT LEAST 72 HOURS SOIL CLASSIFICATION . . . . . . . . 1
PRIOR TO COMMENCING WORK ON SITE. DESIGN PERCOLATION RATE . . . . . < 5 MIN./IN.
7) CONTRACTOR IS TO VERIFY GRADES AND ELEVATIONS AS WELL.AS EFFLUENT LOADING RATE . 74 GAL/DA Y/S.F.
SITE CONDITIONS PRIOR TO COMMENCING WORK ON SITE. LEACHING CAPACITY (AREA X RATE) 381 GAL/DA Y
8) PARCEL IS IN 'FLOOD ZONE_"C RESERVE LEACHING CAPACITY . 381 GAL/DAY
9) LOT IS SHOWN ON ASSESSORS MAP _47— AS PARCEL _ 12-11_ (38x11x 74)+(38f38f11f11x. 74)
SHEET 2 OF 2 JOB NUMBER _ 51349 ......